In [1]:
# ! pip install -U pip setuptools wheel
# ! pip install spacy==3.7.5
# ! python -m spacy download en_core_web_sm
# !pip install scispacy
# !pip install https://s3-us-west-2.amazonaws.com/ai2-s2-scispacy/releases/v0.5.4/en_core_sci_md-0.5.4.tar.gz
# !pip install https://s3-us-west-2.amazonaws.com/ai2-s2-scispacy/releases/v0.5.4/en_ner_craft_md-0.5.4.tar.gz
# !pip install https://s3-us-west-2.amazonaws.com/ai2-s2-scispacy/releases/v0.5.4/en_ner_jnlpba_md-0.5.4.tar.gz
# !pip install https://s3-us-west-2.amazonaws.com/ai2-s2-scispacy/releases/v0.5.4/en_ner_bc5cdr_md-0.5.4.tar.gz
# !pip install https://s3-us-west-2.amazonaws.com/ai2-s2-scispacy/releases/v0.5.4/en_ner_bionlp13cg_md-0.5.4.tar.gz
# !pip install https://s3-us-west-2.amazonaws.com/ai2-s2-scispacy/releases/v0.5.4/en_core_sci_lg-0.5.4.tar.gz
# !pip install gensim
# !pip install transformers
In [2]:
import warnings
warnings.filterwarnings("ignore")
import pandas as pd
import numpy as np
import matplotlib.pyplot as plt
import seaborn as sns
import datetime
from pandas import read_csv
from wordcloud import WordCloud
import spacy
pd.set_option('display.max_rows', None)
In [3]:
# Load all required data files: DEMO data
patients = pd.read_csv("C:\\Users\\harsh\\Desktop\\HBK008\\Holland Bloorview\\projects\\AI4H_UT\\full_dataset\\PATIENTS.csv")
admissions = pd.read_csv("C:\\Users\\harsh\\Desktop\\HBK008\\Holland Bloorview\\projects\\AI4H_UT\\full_dataset\\ADMISSIONS.csv")
prescriptions = pd.read_csv("C:\\Users\\harsh\\Desktop\\HBK008\\Holland Bloorview\\projects\\AI4H_UT\\full_dataset\\PRESCRIPTIONS.csv")
microbiologyevents = pd.read_csv("C:\\Users\\harsh\\Desktop\\HBK008\\Holland Bloorview\\projects\\AI4H_UT\\full_dataset\\MICROBIOLOGYEVENTS.csv")
diagnoses_icd = pd.read_csv("C:\\Users\\harsh\\Desktop\\HBK008\\Holland Bloorview\\projects\\AI4H_UT\\full_dataset\\DIAGNOSES_ICD.csv")
In [4]:
noteevents = pd.read_csv("C:\\Users\\harsh\\Desktop\\HBK008\\Holland Bloorview\\projects\\AI4H_UT\\full_dataset\\NOTEEVENTS.csv.gz")
In [5]:
noteevents.head()
Out[5]:
| ROW_ID | SUBJECT_ID | HADM_ID | CHARTDATE | CHARTTIME | STORETIME | CATEGORY | DESCRIPTION | CGID | ISERROR | TEXT | |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 0 | 174 | 22532 | 167853.0 | 2151-08-04 | NaN | NaN | Discharge summary | Report | NaN | NaN | Admission Date: [**2151-7-16**] Dischar... |
| 1 | 175 | 13702 | 107527.0 | 2118-06-14 | NaN | NaN | Discharge summary | Report | NaN | NaN | Admission Date: [**2118-6-2**] Discharg... |
| 2 | 176 | 13702 | 167118.0 | 2119-05-25 | NaN | NaN | Discharge summary | Report | NaN | NaN | Admission Date: [**2119-5-4**] D... |
| 3 | 177 | 13702 | 196489.0 | 2124-08-18 | NaN | NaN | Discharge summary | Report | NaN | NaN | Admission Date: [**2124-7-21**] ... |
| 4 | 178 | 26880 | 135453.0 | 2162-03-25 | NaN | NaN | Discharge summary | Report | NaN | NaN | Admission Date: [**2162-3-3**] D... |
In [6]:
noteevents_cols = list(noteevents.columns)
noteevents_cols
Out[6]:
['ROW_ID', 'SUBJECT_ID', 'HADM_ID', 'CHARTDATE', 'CHARTTIME', 'STORETIME', 'CATEGORY', 'DESCRIPTION', 'CGID', 'ISERROR', 'TEXT']
In [7]:
noteevents.shape
Out[7]:
(2083180, 11)
In [9]:
diagnoses_icd.info()
diagnoses_icd.iloc[0]
print(diagnoses_icd.iloc[0])
print(diagnoses_icd.columns)
print(len(diagnoses_icd))
<class 'pandas.core.frame.DataFrame'> RangeIndex: 651047 entries, 0 to 651046 Data columns (total 5 columns): # Column Non-Null Count Dtype --- ------ -------------- ----- 0 ROW_ID 651047 non-null int64 1 SUBJECT_ID 651047 non-null int64 2 HADM_ID 651047 non-null int64 3 SEQ_NUM 651000 non-null float64 4 ICD9_CODE 651000 non-null object dtypes: float64(1), int64(3), object(1) memory usage: 24.8+ MB ROW_ID 1297 SUBJECT_ID 109 HADM_ID 172335 SEQ_NUM 1.0 ICD9_CODE 40301 Name: 0, dtype: object Index(['ROW_ID', 'SUBJECT_ID', 'HADM_ID', 'SEQ_NUM', 'ICD9_CODE'], dtype='object') 651047
In [11]:
subarr=diagnoses_icd[diagnoses_icd['ICD9_CODE']=='E8881']['SUBJECT_ID'].to_numpy()
print(len(subarr))
arr_subject_id=[]
arr_hadm_id=[]
for row in range(0, len(diagnoses_icd)):
if(diagnoses_icd.loc[row, 'ICD9_CODE']=='E8881'):
arr_subject_id.append(diagnoses_icd.loc[row, 'SUBJECT_ID'])
# print(diagnoses_icd_df.loc[row, 'SUBJECT_ID'])
print('length of array is:',len(arr_subject_id))
74 length of array is: 74
In [12]:
icd9_E8881_patients_discharge_summary_df = pd.DataFrame(columns=['SUBJECT_ID', 'CATEGORY', 'TEXT'])
patients_dict = {"SUBJECT_ID":[],"CATEGORY":[],"TEXT":[]};
In [15]:
for i in range(0, len(noteevents)):
if((noteevents.loc[i, 'SUBJECT_ID'] in arr_subject_id) and (noteevents.loc[i, 'CATEGORY'] == 'Nutrition')):
patients_dict["SUBJECT_ID"].append(noteevents.loc[i, 'SUBJECT_ID'])
patients_dict["CATEGORY"].append(noteevents.loc[i, 'CATEGORY'])
patients_dict["TEXT"].append(noteevents.loc[i, 'TEXT'])
In [16]:
patients_df = pd.DataFrame(patients_dict)
patients_df.shape
Out[16]:
(22, 3)
In [17]:
print(patients_df.iloc[0]['TEXT'])
Patient transferred to MICU for concern for aspiration. Diet changed to NPO; NGT in for medication. Noted plan to transition to comfort focused care. Will sign off at this time. Please consult if needed. Pager *[**Numeric Identifier 5307**]
In [18]:
import os
path = r'C:\Users\harsh\Desktop\HBK008\Holland Bloorview\projects\AI4H_UT'
patients_df.to_csv(os.path.join(path, r'ICD9-E8881_Patients_NutritionNotes.csv'), index=False)
In [22]:
nlp = spacy.load('en_core_web_sm')
notes = []
with open('ICD9-E8881_Patients_NutritionNotes.csv', 'r') as fin:
lines = fin.readlines()
for line in lines:
notes.append(line)
print(notes)
print(len(notes))
['SUBJECT_ID,CATEGORY,TEXT\n', '17610,Nutrition,"Patient transferred to MICU for concern for aspiration. Diet changed\n', ' to NPO; NGT in for medication. Noted plan to transition to comfort\n', ' focused care.\n', ' Will sign off at this time. Please consult if needed. Pager *[**Numeric Identifier 5307**]\n', '"\n', '40493,Nutrition,"Objective\n', ' Pertinent medications: RISS, SS lytes, thiamin, folate, lasix, bowel\n', ' regimen, MOM, reglan, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 93 mg/dL\n', ' [**2172-11-9**] 01:50 AM\n', ' Glucose Finger Stick\n', ' 120\n', ' [**2172-11-9**] 08:57 AM\n', ' BUN\n', ' 15 mg/dL\n', ' [**2172-11-9**] 01:50 AM\n', ' Creatinine\n', ' 0.6 mg/dL\n', ' [**2172-11-9**] 01:50 AM\n', ' Sodium\n', ' 137 mEq/L\n', ' [**2172-11-9**] 01:50 AM\n', ' Potassium\n', ' 3.9 mEq/L\n', ' [**2172-11-9**] 01:50 AM\n', ' Chloride\n', ' 106 mEq/L\n', ' [**2172-11-9**] 01:50 AM\n', ' TCO2\n', ' 24 mEq/L\n', ' [**2172-11-9**] 01:50 AM\n', ' PO2 (arterial)\n', ' 66 mm Hg\n', ' [**2172-11-9**] 08:57 AM\n', ' PCO2 (arterial)\n', ' 41 mm Hg\n', ' [**2172-11-9**] 08:57 AM\n', ' pH (arterial)\n', ' 7.42 units\n', ' [**2172-11-9**] 08:57 AM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2172-11-1**] 06:06 PM\n', ' CO2 (Calc) arterial\n', ' 28 mEq/L\n', ' [**2172-11-9**] 08:57 AM\n', ' Albumin\n', ' 2.6 g/dL\n', ' [**2172-11-3**] 02:24 AM\n', ' Calcium non-ionized\n', ' 8.7 mg/dL\n', ' [**2172-11-9**] 01:50 AM\n', ' Phosphorus\n', ' 4.5 mg/dL\n', ' [**2172-11-9**] 01:50 AM\n', ' Ionized Calcium\n', ' 1.11 mmol/L\n', ' [**2172-11-5**] 01:34 PM\n', ' Magnesium\n', ' 2.2 mg/dL\n', ' [**2172-11-9**] 01:50 AM\n', ' Current diet order / nutrition support: Fibersource HN@60mL/hr (1728\n', ' kcals/73 gr aa) not infusing\n', ' GI: Abd soft/+bs\n', ' Assessment of Nutritional Status\n', ' Specifics:\n', ' Pt extubated earlier today. Pt was previously tolerating TF\n', 's @ goal,\n', ' meeting 100% estimated nutrition needs. Anticipate diet advancement as\n', ' able.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Advance diet per team c/ swallow eval if pt shows s/s of aspiration and\n', " advance diet per SLP- vs place NGT and resume TF's if unable to take\n", ' po\n', " Will follow plan -please page c/ ?'s #[**Numeric Identifier 1684**]\n", '"\n', '40493,Nutrition,"Subjective\n', ' intubated\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 168 cm\n', ' 65 kg\n', ' 23.1\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 64.4 kg\n', ' 101%\n', ' Diagnosis: S/P Fall\n', ' PMH : etoh, smoker, cirrhosis\n', ' Food allergies and intolerances: NKFA\n', ' Pertinent medications: fentanyl, LR @ 10 ml/hr, lasix, versed, RISS, IV\n', ' abx, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 155 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Glucose Finger Stick\n', ' 151\n', ' [**2172-11-2**] 08:00 AM\n', ' BUN\n', ' 17 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Creatinine\n', ' 0.8 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Sodium\n', ' 146 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' Potassium\n', ' 3.6 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' Chloride\n', ' 111 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' TCO2\n', ' 29 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' PO2 (arterial)\n', ' 113 mm Hg\n', ' [**2172-11-2**] 11:55 AM\n', ' PCO2 (arterial)\n', ' 41 mm Hg\n', ' [**2172-11-2**] 11:55 AM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2172-11-2**] 11:55 AM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2172-11-1**] 06:06 PM\n', ' CO2 (Calc) arterial\n', ' 30 mEq/L\n', ' [**2172-11-2**] 11:55 AM\n', ' Albumin\n', ' 3.0 g/dL\n', ' [**2172-10-31**] 02:55 AM\n', ' Calcium non-ionized\n', ' 8.1 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Phosphorus\n', ' 2.5 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Ionized Calcium\n', ' 1.16 mmol/L\n', ' [**2172-11-2**] 11:55 AM\n', ' Magnesium\n', ' 1.7 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' ALT\n', ' 14 IU/L\n', ' [**2172-10-31**] 02:55 AM\n', ' Alkaline Phosphate\n', ' 73 IU/L\n', ' [**2172-10-31**] 02:55 AM\n', ' AST\n', ' 43 IU/L\n', ' [**2172-10-31**] 02:55 AM\n', ' Total Bilirubin\n', ' 3.4 mg/dL\n', ' [**2172-10-31**] 02:55 AM\n', ' WBC\n', ' 23.2 K/uL\n', ' [**2172-11-2**] 01:06 AM\n', ' Hgb\n', ' 9.1 g/dL\n', ' [**2172-11-2**] 01:06 AM\n', ' Hematocrit\n', ' 27.2 %\n', ' [**2172-11-2**] 01:06 AM\n', ' Current diet order / nutrition support: NPO replete with fiber @ 60\n', ' ml/hr\n', ' GI: OGT\n', ' Assessment of Nutritional Status\n', ' At risk for malnutrition\n', ' Pt at risk due to: NPO / hypocaloric diet\n', ' Estimated Nutritional Needs\n', ' Calories: 1625-[**2114**] (25-30 cal/kg)\n', ' Protein: 78-91 (1.2-1.4 g/kg)\n', ' Fluid: per team\n', ' Estimation of previous intake: Likely Adequate\n', ' Estimation of current intake: Inadequate\n', ' Specifics: 57 year old male transferred from OSH, intubated there. Pt\n', ' S/P fall CT shows Stage IV splenic laceration. Tolerating TF with\n', ' minimal residuals [**Name8 (MD) **] RN. Current TF provides 1440 kcals/89 g Pro.\n', ' Recommend changing TF to better meet nutritional needs.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' 1. Check chemistry 10 panel daily\n', ' 2. Change TF to goal of Fibersource HN @ 65ml/hr (1872 kcals/83 g\n', ' Pro)\n', ' 3. Pls page with questions [**Numeric Identifier 2584**]\n', '"\n', '40493,Nutrition,"Subjective\n', ' intubated\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 168 cm\n', ' 65 kg\n', ' 23.1\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 64.4 kg\n', ' 101%\n', ' Diagnosis: S/P Fall\n', ' PMH : etoh, smoker, cirrhosis\n', ' Food allergies and intolerances: NKFA\n', ' Pertinent medications: fentanyl, LR @ 10 ml/hr, lasix, versed, RISS, IV\n', ' abx, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 155 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Glucose Finger Stick\n', ' 151\n', ' [**2172-11-2**] 08:00 AM\n', ' BUN\n', ' 17 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Creatinine\n', ' 0.8 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Sodium\n', ' 146 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' Potassium\n', ' 3.6 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' Chloride\n', ' 111 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' TCO2\n', ' 29 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' PO2 (arterial)\n', ' 113 mm Hg\n', ' [**2172-11-2**] 11:55 AM\n', ' PCO2 (arterial)\n', ' 41 mm Hg\n', ' [**2172-11-2**] 11:55 AM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2172-11-2**] 11:55 AM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2172-11-1**] 06:06 PM\n', ' CO2 (Calc) arterial\n', ' 30 mEq/L\n', ' [**2172-11-2**] 11:55 AM\n', ' Albumin\n', ' 3.0 g/dL\n', ' [**2172-10-31**] 02:55 AM\n', ' Calcium non-ionized\n', ' 8.1 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Phosphorus\n', ' 2.5 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Ionized Calcium\n', ' 1.16 mmol/L\n', ' [**2172-11-2**] 11:55 AM\n', ' Magnesium\n', ' 1.7 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' ALT\n', ' 14 IU/L\n', ' [**2172-10-31**] 02:55 AM\n', ' Alkaline Phosphate\n', ' 73 IU/L\n', ' [**2172-10-31**] 02:55 AM\n', ' AST\n', ' 43 IU/L\n', ' [**2172-10-31**] 02:55 AM\n', ' Total Bilirubin\n', ' 3.4 mg/dL\n', ' [**2172-10-31**] 02:55 AM\n', ' WBC\n', ' 23.2 K/uL\n', ' [**2172-11-2**] 01:06 AM\n', ' Hgb\n', ' 9.1 g/dL\n', ' [**2172-11-2**] 01:06 AM\n', ' Hematocrit\n', ' 27.2 %\n', ' [**2172-11-2**] 01:06 AM\n', ' Current diet order / nutrition support: NPO replete with fiber @ 60\n', ' ml/hr\n', ' GI: OGT\n', ' Assessment of Nutritional Status\n', ' At risk for malnutrition\n', ' Pt at risk due to: NPO / hypocaloric diet\n', ' Estimated Nutritional Needs\n', ' Calories: 1625-[**2114**] (25-30 cal/kg)\n', ' Protein: 78-91 (1.2-1.4 g/kg)\n', ' Fluid: per team\n', ' Estimation of previous intake: Likely Adequate\n', ' Estimation of current intake: Inadequate\n', ' Specifics: 57 year old male transferred from OSH, intubated there. Pt\n', ' S/P fall CT shows Stage IV splenic laceration. Tolerating TF with\n', ' minimal residuals [**Name8 (MD) **] RN. Current TF provides 1440 kcals/89 g Pro.\n', ' Recommend changing TF to better meet nutritional needs.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' 1. Check chemistry 10 panel daily\n', ' 2. Change TF to goal of Fibersource HN @ 65ml/hr (1872 kcals/83 g\n', ' Pro)\n', ' 3. Pls page with questions [**Numeric Identifier 2584**]\n', '"\n', '61565,Nutrition,"Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 88.2 kg\n', ' 27.8\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 75.3 kg\n', ' 117%\n', ' Diagnosis: Head Bleed\n', ' PMH : DM.\n', ' Food allergies and intolerances:\n', ' Pertinent medications: Esmolol, famotidine, colace, lytes ss, dilantin,\n', ' ssri, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 143 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Glucose Finger Stick\n', ' 155\n', ' [**2100-11-1**] 02:00 AM\n', ' BUN\n', ' 18 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Creatinine\n', ' 0.8 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Sodium\n', ' 142 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' Potassium\n', ' 4.1 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' Chloride\n', ' 111 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' TCO2\n', ' 26 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' PO2 (arterial)\n', ' 109 mm Hg\n', ' [**2100-11-1**] 04:35 AM\n', ' PCO2 (arterial)\n', ' 38 mm Hg\n', ' [**2100-11-1**] 04:35 AM\n', ' pH (arterial)\n', ' 7.48 units\n', ' [**2100-11-1**] 04:35 AM\n', ' CO2 (Calc) arterial\n', ' 29 mEq/L\n', ' [**2100-11-1**] 04:35 AM\n', ' Albumin\n', ' 3.8 g/dL\n', ' [**2100-10-30**] 03:27 AM\n', ' Calcium non-ionized\n', ' 8.9 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Phosphorus\n', ' 2.5 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Ionized Calcium\n', ' 1.22 mmol/L\n', ' [**2100-10-31**] 02:41 AM\n', ' Magnesium\n', ' 2.3 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Phenytoin (Dilantin)\n', ' 10.1 ug/mL\n', ' [**2100-10-31**] 02:34 AM\n', ' WBC\n', ' 12.1 K/uL\n', ' [**2100-11-1**] 02:37 AM\n', ' Hgb\n', ' 11.9 g/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Hematocrit\n', ' 33.9 %\n', ' [**2100-11-1**] 02:37 AM\n', ' Current diet order / nutrition support: Replete with fiber Full\n', ' strength; Goal rate: 65 ml/hr\n', ' Residual Check: q4h Hold feeding for residual >= : 200 ml\n', ' GI:\n', ' Assessment of Nutritional Status\n', ' At risk for malnutrition\n', ' Pt at risk due to: NPO / hypocaloric diet\n', ' Estimated Nutritional Needs\n', ' Calories: [**2027**]-2200 (BEE x or / 22-25 cal/kg)\n', ' Protein: 114 (1.3 g/kg)\n', ' Fluid:\n', ' Estimation of previous intake: Adequate\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' 72 yo male s/p witnessed fall w/ head trauma, right parietal-occipital\n', ' SAH w/ left intraparenchymal bleed / contre-coup injury. Pt started on\n', ' TF yesterday, currently tol goal TF without issue, per chart, pt with +\n', ' gag, will plan to extubate this am. If unable to extubate, will need\n', " to change TF to better meet pt's needs.\n", ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Tube feeding recommendations:\n', ' Check chemistry 10 panel daily and replete\n', ' Cont Bg management\n', ' Pplease page [**Numeric Identifier 1550**] if has ?\n', '"\n', '61565,Nutrition,"Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm est.\n', ' 88.2 kg\n', ' 27.8\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 75.3 kg\n', ' 117%\n', ' Diagnosis: Head Bleed\n', ' PMH : DM, HTN\n', ' Food allergies and intolerances:\n', ' Pertinent medications: Esmolol, famotidine, colace, lytes ss, dilantin,\n', ' ssri, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 143 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Glucose Finger Stick\n', ' 155\n', ' [**2100-11-1**] 02:00 AM\n', ' BUN\n', ' 18 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Creatinine\n', ' 0.8 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Sodium\n', ' 142 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' Potassium\n', ' 4.1 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' Chloride\n', ' 111 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' TCO2\n', ' 26 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' PO2 (arterial)\n', ' 109 mm Hg\n', ' [**2100-11-1**] 04:35 AM\n', ' PCO2 (arterial)\n', ' 38 mm Hg\n', ' [**2100-11-1**] 04:35 AM\n', ' pH (arterial)\n', ' 7.48 units\n', ' [**2100-11-1**] 04:35 AM\n', ' CO2 (Calc) arterial\n', ' 29 mEq/L\n', ' [**2100-11-1**] 04:35 AM\n', ' Albumin\n', ' 3.8 g/dL\n', ' [**2100-10-30**] 03:27 AM\n', ' Calcium non-ionized\n', ' 8.9 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Phosphorus\n', ' 2.5 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Ionized Calcium\n', ' 1.22 mmol/L\n', ' [**2100-10-31**] 02:41 AM\n', ' Magnesium\n', ' 2.3 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Phenytoin (Dilantin)\n', ' 10.1 ug/mL\n', ' [**2100-10-31**] 02:34 AM\n', ' WBC\n', ' 12.1 K/uL\n', ' [**2100-11-1**] 02:37 AM\n', ' Hgb\n', ' 11.9 g/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Hematocrit\n', ' 33.9 %\n', ' [**2100-11-1**] 02:37 AM\n', ' Current diet order / nutrition support: Replete with fiber Full\n', ' strength; Goal rate: 65 ml/hr (1560kcal/96.7g pro)\n', ' Residual Check: q4h Hold feeding for residual >= : 200 ml\n', ' GI: Soft, Non-distended, Non-tender\n', ' Assessment of Nutritional Status\n', ' At risk for malnutrition\n', ' Pt at risk due to: NPO\n', ' Estimated Nutritional Needs\n', ' Calories: 1760-2200 (BEE x or / 20-25 cal/kg)\n', ' Protein: 114 (1.3 g/kg)\n', ' Fluid: per team\n', ' Estimation of previous intake: likely adequate\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' 72 yo male s/p witnessed fall w/ head trauma, right parietal-occipital\n', ' SAH w/ left intraparenchymal bleed / contre-coup injury. Pt started on\n', ' TF yesterday, currently tol goal TF without issue, per chart, pt with +\n', ' gag, cough, [**Last Name (LF) 1080**], [**First Name3 (LF) **] plan to extubate this am. If unable to\n', " extubate, will need to change TF to better meet pt's needs.\n", ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Tube feeding recommendations: increase TF to Replete with Fiber goal\n', ' 75ml/hr (1800kcal/112g pro)\n', ' Check chemistry 10 panel daily and replete prn\n', ' Cont Bg management\n', ' Please page [**Numeric Identifier 1550**] if has ?\n', '"\n', '61565,Nutrition,"Objective\n', ' Pertinent medications: pepcid, Heparin, docusate, Abx, RISS, others\n', ' noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 128 mg/dL\n', ' [**2100-11-5**] 03:32 AM\n', ' Glucose Finger Stick\n', ' 140\n', ' [**2100-11-4**] 08:00 PM\n', ' BUN\n', ' 18 mg/dL\n', ' [**2100-11-5**] 03:32 AM\n', ' Creatinine\n', ' 0.7 mg/dL\n', ' [**2100-11-5**] 03:32 AM\n', ' Sodium\n', ' 140 mEq/L\n', ' [**2100-11-5**] 03:32 AM\n', ' Potassium\n', ' 3.9 mEq/L\n', ' [**2100-11-5**] 03:32 AM\n', ' Chloride\n', ' 103 mEq/L\n', ' [**2100-11-5**] 03:32 AM\n', ' TCO2\n', ' 28 mEq/L\n', ' [**2100-11-5**] 03:32 AM\n', ' PO2 (arterial)\n', ' 94.[**Numeric Identifier 126**] mm Hg\n', ' [**2100-11-5**] 07:26 AM\n', ' PCO2 (arterial)\n', ' 37 mm Hg\n', ' [**2100-11-5**] 07:26 AM\n', ' pH (arterial)\n', ' 7.49 units\n', ' [**2100-11-5**] 07:26 AM\n', ' pH (urine)\n', ' 7.0 units\n', ' [**2100-11-5**] 11:05 AM\n', ' CO2 (Calc) arterial\n', ' 29 mEq/L\n', ' [**2100-11-5**] 07:26 AM\n', ' Calcium non-ionized\n', ' 8.7 mg/dL\n', ' [**2100-11-4**] 02:31 AM\n', ' Phosphorus\n', ' 3.0 mg/dL\n', ' [**2100-11-4**] 02:31 AM\n', ' Magnesium\n', ' 2.3 mg/dL\n', ' [**2100-11-4**] 02:31 AM\n', ' WBC\n', ' 12.2 K/uL\n', ' [**2100-11-5**] 03:32 AM\n', ' Hgb\n', ' 12.0 g/dL\n', ' [**2100-11-5**] 03:32 AM\n', ' Hematocrit\n', ' 33.8 %\n', ' [**2100-11-5**] 03:32 AM\n', ' Current diet order / nutrition support: Replete c/ Fiber @65mL/hr (1560\n', ' kcals/97 gr aa)\n', ' GI: Abd: soft/+bs\n', ' Assessment of Nutritional Status\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' Pt s/p trach/PEG/and IVC filter yesterday. TF\n', 's currently infusing @\n', ' 10mL/hr. Current goal Rx will meet 88% estimated kcal and 85% estimated\n', ' aa needs therefore, will need to increase goal rate of TF\n', 's to avoid\n', ' underfeeding. .\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Multivitamin / Mineral supplement: vua TF\n', ' Tube feeding recommendations: Increase TF goal rate to 75 mL/hr (1800\n', ' kcals/112 gr aa)\n', ' BG management as you are\n', " Please page c/?'s #[**Numeric Identifier 1684**]\n", '"\n', '98851,Nutrition,"Patient has been NPO and/or on unsupplemented clear liquid diet for 1\n', " days. If patient's diet is not able to be advanced and tolerated,\n", ' [**Street Address(1) 1511**] for nutrition support\n', ' Potential for nutrition risk. Patient being monitored. Current\n', ' intervention if any, listed below:\n', ' Comments:\n', ' Pt s/p LRRT [**4-17**], c/b hypoxia and increased O2 requirements in PACU, on\n', ' clears, tolerating well. Clinically improving, possibly transfer to\n', ' floor soon.\n', ' If unable to advance diet further in 24-48hrs, patient may benefit from\n', ' nutrition support.\n', ' Will f/u with progress, po tolerance.\n', ' Please page w/ questions #[**Numeric Identifier 1687**]\n', ' 12:11\n', '"\n', '58054,Nutrition,"Comments:\n', ' Screening per hospital nutrition protocol. Noted patient is comfort\n', ' measures only. No nutrition support indicated at this time. Will sign\n', ' off. Please consult if needed. #[**Numeric Identifier 2337**]\n', '"\n', '99573,Nutrition,"Subjective\n', ' patient confused, unable to answer questions per chart patient had\n', ' difficulty swallowing PTA d/t damaged salivary glands from XRT\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 168 cm\n', ' 98.2 kg\n', ' 34.9\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 59 kg\n', ' 166%\n', ' 68.8 kg\n', ' Diagnosis: facial fx\n', ' PMH : breast ca, tongue ca, ovarian ca, polymyalgia, NIDDM, vertigo, hx\n', ' of falls\n', ' Food allergies and intolerances: none noted\n', ' Pertinent medications: RISS, IV abx, protonix, KCl (30 mEq), Dextrose\n', ' 5% 1/2 normal saline with KCl, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 206\n', ' [**2181-6-5**] 08:00 AM\n', ' Glucose Finger Stick\n', ' 222\n', ' [**2181-6-4**] 08:00 PM\n', ' BUN\n', ' 11 mg/dL\n', ' [**2181-6-4**] 11:36 PM\n', ' Creatinine\n', ' 0.5 mg/dL\n', ' [**2181-6-4**] 11:36 PM\n', ' Sodium\n', ' 134 mEq/L\n', ' [**2181-6-4**] 11:36 PM\n', ' Potassium\n', ' 4.1 mEq/L\n', ' [**2181-6-5**] 09:13 AM\n', ' Chloride\n', ' 98 mEq/L\n', ' [**2181-6-4**] 11:36 PM\n', ' TCO2\n', ' 26 mEq/L\n', ' [**2181-6-4**] 11:36 PM\n', ' pH (urine)\n', ' 6.5 units\n', ' [**2181-6-3**] 12:30 AM\n', ' Calcium non-ionized\n', ' 8.5 mg/dL\n', ' [**2181-6-4**] 11:36 PM\n', ' Phosphorus\n', ' 2.3 mg/dL\n', ' [**2181-6-4**] 11:36 PM\n', ' Magnesium\n', ' 2.0 mg/dL\n', ' [**2181-6-4**] 11:36 PM\n', ' WBC\n', ' 9.2 K/uL\n', ' [**2181-6-5**] 12:03 AM\n', ' Hgb\n', ' 10.9 g/dL\n', ' [**2181-6-5**] 12:03 AM\n', ' Hematocrit\n', ' 32.7 %\n', ' [**2181-6-5**] 12:03 AM\n', ' Current diet order / nutrition support: NPO\n', ' GI: obese, + bowel sounds\n', ' Assessment of Nutritional Status\n', ' Obese, At risk for malnutrition\n', ' Pt at risk due to: NPO / hypocaloric diet, trauma\n', ' Estimated Nutritional Needs based on adjusted body wt\n', ' Calories: 1513-1720 (22-25 cal/kg)\n', ' Protein: 83-103 (1.2-1.5 g/kg)\n', ' Fluid: per team\n', ' Estimation of previous intake: unknown\n', ' Estimation of current intake: Inadequate d/t NPO status\n', ' Specifics: 78 year old female admitted from outside hospital S/P fall\n', ' at home with multiple injuries including Le Forte fx, multiple sinus\n', ' fx, orbital fx, facial and tongue swelling. Patient seen by SLP on [**6-4**]\n', ' who recommended patient remain NPO. If patient\n', 's diet cannot be\n', ' advanced consider initiating tube feedings to prevent further\n', ' nutritional decline.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' If diet cannot be advanced recommend starting tube feedings start with\n', ' Replete with Fiber @ 15 ml/hr advance to goal of 65 ml/hr =1560\n', ' kcals/97 g protein\n', ' Check residuals q 4-6 hours hold if greater than 150 cc\n', ' Monitor lytes and glucose with initiation of tube feeding\n', ' Change to non-dextrose IV fluids once tube feedings started\n', ' Implement any SLP recs\n', ' Will continue to follow page [**Numeric Identifier 1372**] with questions\n', '"\n', '40461,Nutrition,"Subjective\n', ' oriented x1\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 74.9 kg ([**2113-2-3**] 04:00 AM)\n', ' 19.9\n', ' Pertinent medications: Ranitidine, Multi-vitamin, ABX, Folic Acid,\n', ' Thiamine, Coumadin, Lasix, Colace (held), KCl (20mEq repletion x2),\n', ' Magnesium sulfate (2g repletion), Heparin drip\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 105 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Glucose Finger Stick\n', ' 127\n', ' [**2113-2-3**] 12:00 PM\n', ' BUN\n', ' 25 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Creatinine\n', ' 1.8 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Sodium\n', ' 142 mEq/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Potassium\n', ' 3.9 mEq/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Chloride\n', ' 110 mEq/L\n', ' [**2113-2-3**] 05:24 AM\n', ' TCO2\n', ' 25 mEq/L\n', ' [**2113-2-3**] 05:24 AM\n', ' PO2 (arterial)\n', ' 65 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 30 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2113-1-31**] 04:47 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.5 units\n', ' [**2113-2-1**] 07:16 AM\n', ' CO2 (Calc) arterial\n', ' 22 mEq/L\n', ' [**2113-1-31**] 04:47 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.1 g/dL\n', ' [**2113-2-1**] 02:44 PM\n', ' Calcium non-ionized\n', ' 7.5 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Phosphorus\n', ' 3.0 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Ionized Calcium\n', ' 1.08 mmol/L\n', ' [**2113-1-30**] 11:46 AM\n', ' Magnesium\n', ' 2.3 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' ALT\n', ' 23 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Alkaline Phosphate\n', ' 51 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' AST\n', ' 24 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Amylase\n', ' 40 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Total Bilirubin\n', ' 0.3 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 9.3 K/uL\n', ' [**2113-2-3**] 05:24 AM\n', ' Hgb\n', ' 8.9 g/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Hematocrit\n', ' 27.0 %\n', ' [**2113-2-3**] 05:24 AM\n', ' Current diet order / nutrition support: Diet: NPO\n', ' Calorie counts: [**2-1**] - 17 - 18\n', ' GI: soft, (+) bowel sounds; 500ml stool today\n', ' Assessment of Nutritional Status\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' 49 year old male with mitral valve endocarditis, preop stroke s/p MVR\n', ' (29mm [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1104**] [**Last Name (NamePattern1) 1105**]) debridement of aortic valve [**1-27**]. Patient with\n', ' prolonged poor po\n', 's during admit. Was on ground solids + thin liquid\n', ' diet, refusing po\n', 's at times. s/p calories counts\n', ' 880 calories [**2-1**]\n', ' and 270 calories [**2-2**]. Seen for video swallow evaluation this AM\n', ' SLP recommend NPO. Per discussion with PA\n', ' plan for PEG placement as\n', ' previously unable to place NGT and feel that patient will pull it out.\n', ' Agree with PEG for long term nutrition support to prevent further\n', ' nutritional decline and optimize nutrition for post-op healing. Noted\n', ' multiple lyte repletions.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Current diet / nutrition support is appropriate: continue\n', ' NPO per SLP recommendations\n', ' o SLP follow up when appropriate\n', ' Tube feeding recommendations: Agree with PEG\n', ' o Once feeding tube placed, recommend begin Isosource 1.5 @\n', ' 20ml/hr, advance as tolerated to goal of 45ml/hr = 1620 calories and\n', ' 73g protein\n', ' Check residuals, hold tube feed if greater than 200ml\n', ' Multivitamin / Mineral supplement: continue current\n', ' Check chemistry 10 panel daily\n', ' o Replete lytes PRN\n', ' Will follow, page if questions *[**Numeric Identifier 606**]\n', '"\n', '40461,Nutrition,"Subjective\n', ' Patient oob, tube feed running at 40 ml/hr.\n', ' Objective\n', ' Pertinent medications: noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 119\n', ' [**2113-2-8**] 08:00 AM\n', ' Glucose Finger Stick\n', ' 150\n', ' [**2113-2-7**] 10:00 PM\n', ' BUN\n', ' 31 mg/dL\n', ' [**2113-2-8**] 02:50 AM\n', ' Creatinine\n', ' 2.0 mg/dL\n', ' [**2113-2-8**] 02:50 AM\n', ' Sodium\n', ' 143 mEq/L\n', ' [**2113-2-8**] 02:50 AM\n', ' Potassium\n', ' 3.4 mEq/L\n', ' [**2113-2-8**] 07:52 AM\n', ' Chloride\n', ' 109 mEq/L\n', ' [**2113-2-8**] 02:50 AM\n', ' TCO2\n', ' 25 mEq/L\n', ' [**2113-2-8**] 02:50 AM\n', ' PO2 (arterial)\n', ' 65 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 30 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2113-1-31**] 04:47 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-2-7**] 05:19 PM\n', ' pH (urine)\n', ' 5.5 units\n', ' [**2113-2-1**] 07:16 AM\n', ' CO2 (Calc) arterial\n', ' 22 mEq/L\n', ' [**2113-1-31**] 04:47 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.2 g/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Calcium non-ionized\n', ' 7.8 mg/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Phosphorus\n', ' 4.0 mg/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Ionized Calcium\n', ' 1.07 mmol/L\n', ' [**2113-2-7**] 05:19 PM\n', ' Magnesium\n', ' 2.1 mg/dL\n', ' [**2113-2-8**] 07:52 AM\n', ' ALT\n', ' 21 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' Alkaline Phosphate\n', ' 50 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' AST\n', ' 23 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' Amylase\n', ' 45 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' Total Bilirubin\n', ' 0.4 mg/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 10.1 K/uL\n', ' [**2113-2-8**] 02:50 AM\n', ' Hgb\n', ' 8.3 g/dL\n', ' [**2113-2-8**] 02:50 AM\n', ' Hematocrit\n', ' 26.1 %\n', ' [**2113-2-8**] 02:50 AM\n', ' Current diet order / nutrition support: Replete with fiber Full\n', ' strength;\n', ' Starting rate: 40 ml/hr; Advance rate by 20 ml q6h Goal rate: 70 ml/hr\n', ' Residual Check: q4h Hold feeding for residual >= : 200 ml\n', ' Flush w/ 30 ml water q8h\n', ' GI: Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n', ' PEG site clean and dry.\n', ' Assessment of Nutritional Status\n', ' 49 year old male s/p PEG placement yesterday, tube feed started\n', ' yesterday, tolerated Isosource 1.5 well, tube feed ordered changed to\n', ' Replete with fiber this morning, spoke to team, does not want patient\n', ' on special tube feed, recommend change to Fibersource HN as current\n', ' formula provides excess amount of protein. Noted discharge planning in\n', ' progress.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Tube feeding: Fibersource HN goal 60ml/hr ( 1728kcal/76g\n', ' protein)\n', ' Check chemistry 10 panel daily, replete prn\n', ' Continue BS management\n', ' [**Numeric Identifier 943**] if has question\n', '"\n', '40461,Nutrition,"Subjective\n', ' Patient asleep.\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 70.8 kg ([**2113-2-7**] 04:00 AM)\n', ' 19.9\n', ' Pertinent medications: Multiple Vitamins, Furosemide, Docusate Sodium,\n', ' others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 157 mg/dL\n', ' [**2113-2-7**] 04:00 AM\n', ' Glucose Finger Stick\n', ' 158\n', ' [**2113-2-7**] 06:00 AM\n', ' BUN\n', ' 33 mg/dL\n', ' [**2113-2-7**] 04:00 AM\n', ' Creatinine\n', ' 1.9 mg/dL\n', ' [**2113-2-7**] 04:00 AM\n', ' Sodium\n', ' 145 mEq/L\n', ' [**2113-2-7**] 04:00 AM\n', ' Potassium\n', ' 3.7 mEq/L\n', ' [**2113-2-7**] 04:00 AM\n', ' Chloride\n', ' 111 mEq/L\n', ' [**2113-2-7**] 04:00 AM\n', ' TCO2\n', ' 24 mEq/L\n', ' [**2113-2-7**] 04:00 AM\n', ' PO2 (arterial)\n', ' 65 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 30 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2113-1-31**] 04:47 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.5 units\n', ' [**2113-2-1**] 07:16 AM\n', ' CO2 (Calc) arterial\n', ' 22 mEq/L\n', ' [**2113-1-31**] 04:47 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.2 g/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Calcium non-ionized\n', ' 7.8 mg/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Phosphorus\n', ' 4.0 mg/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Ionized Calcium\n', ' 1.08 mmol/L\n', ' [**2113-1-30**] 11:46 AM\n', ' Magnesium\n', ' 2.0 mg/dL\n', ' [**2113-2-6**] 11:00 PM\n', ' ALT\n', ' 21 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' Alkaline Phosphate\n', ' 50 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' AST\n', ' 23 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' Amylase\n', ' 45 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' Total Bilirubin\n', ' 0.4 mg/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 12.3 K/uL\n', ' [**2113-2-7**] 04:00 AM\n', ' Hgb\n', ' 8.8 g/dL\n', ' [**2113-2-7**] 04:00 AM\n', ' Hematocrit\n', ' 26.9 %\n', ' [**2113-2-7**] 04:00 AM\n', ' Current diet order / nutrition support: Non-Standard TPN For Date:\n', ' [**2113-2-6**] (1600ml, 270drextrose/80protein/35fat)\n', ' Replete with fiber Full strength;\n', ' Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 60 ml/hr\n', ' Residual Check: q4h Hold feeding for residual >= : 200 ml\n', ' Flush w/ 30 ml water q8h\n', ' GI: Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n', ' PEG site clean and dry. Peg to gravity drainage\n', ' Assessment of Nutritional Status\n', ' 49 year old male with Mitral valve endocarditis, preop stroke s/p MVR\n', ' and debridement of aortic valve [**1-27**], patient failed S & S evaluation,\n', ' TPN started over the weekend while awaiting PEG. PEG placed\n', ' yesterday, plan to start tube feeds today, current tube feed order not\n', ' meeting patient\n', 's estimated need. Noted patient with post op fluid\n', ' gain, recommend fluid restricted formula.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Consider ordering day 1 TPN tonight while slowly advancing\n', ' tube feed\n', ' Tube feeding: Isosource 1.5cal goal 45ml/hr ( 1620kcal/73g\n', ' protein)\n', ' Start tube feed at 15ml/hr and adv slowly as tol\n', ' Check chemistry 10 panel daily, replete prn\n', ' Continue BS management\n', ' [**Numeric Identifier 943**] if has question\n', '"\n', '40461,Nutrition,"Subjective\n', ' patient sleeping\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 74.9 kg ([**2113-2-3**] 04:00 AM)\n', ' 19.9\n', ' Pertinent medications: D5 @10 ml/hr, KCl (40 mEq repletion), RISS, IV\n', ' abx, lansoprazole, famotidine, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 73\n', ' [**2113-2-4**] 12:00 PM\n', ' Glucose Finger Stick\n', ' 135\n', ' [**2113-2-4**] 12:00 AM\n', ' BUN\n', ' 25 mg/dL\n', ' [**2113-2-4**] 03:42 AM\n', ' Creatinine\n', ' 1.6 mg/dL\n', ' [**2113-2-4**] 03:42 AM\n', ' Sodium\n', ' 140 mEq/L\n', ' [**2113-2-4**] 03:42 AM\n', ' Potassium\n', ' 3.5 mEq/L\n', ' [**2113-2-4**] 03:42 AM\n', ' Chloride\n', ' 108 mEq/L\n', ' [**2113-2-4**] 03:42 AM\n', ' TCO2\n', ' 22 mEq/L\n', ' [**2113-2-4**] 03:42 AM\n', ' PO2 (arterial)\n', ' 65 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 30 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2113-1-31**] 04:47 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.5 units\n', ' [**2113-2-1**] 07:16 AM\n', ' CO2 (Calc) arterial\n', ' 22 mEq/L\n', ' [**2113-1-31**] 04:47 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.1 g/dL\n', ' [**2113-2-1**] 02:44 PM\n', ' Calcium non-ionized\n', ' 7.3 mg/dL\n', ' [**2113-2-4**] 03:42 AM\n', ' Phosphorus\n', ' 3.1 mg/dL\n', ' [**2113-2-4**] 03:42 AM\n', ' Ionized Calcium\n', ' 1.08 mmol/L\n', ' [**2113-1-30**] 11:46 AM\n', ' Magnesium\n', ' 2.0 mg/dL\n', ' [**2113-2-4**] 03:42 AM\n', ' ALT\n', ' 23 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Alkaline Phosphate\n', ' 51 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' AST\n', ' 24 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Amylase\n', ' 40 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Total Bilirubin\n', ' 0.3 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 13.4 K/uL\n', ' [**2113-2-4**] 03:42 AM\n', ' Hgb\n', ' 9.8 g/dL\n', ' [**2113-2-4**] 03:42 AM\n', ' Hematocrit\n', ' 29.7 %\n', ' [**2113-2-4**] 03:42 AM\n', ' Current diet order / nutrition support: NPO\n', ' GI: soft, hypoactive bowel sounds\n', ' Assessment of Nutritional Status\n', ' Specifics: Patient s/p video swallow [**2-3**] which recommended patient be\n', ' NPO. Received consult for PPN recommendations. Per discussion with PA,\n', ' plan is for PEG placement on Monday and to supplement nutrition with\n', ' parenteral nutrition until PEG is able to be used. Patient with PICC,\n', ' Day 1 TPN ordered to start tonight. NGT was attempted earlier in week\n', ' and was unable to placed and team thinks patient would pull it out.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' 1. Day 1 TPN tonight\n', ' 2. Pending glycemic control advance to goal TPN 1.6L (270 g\n', ' dextrose/80 g amino acids/35 g lipids)= 1588 kcals\n', ' 3. Check TG hold lipids if greater than 400\n', ' 4. Once PEG placed start with Isosource HN @ 15 ml/hr advance to\n', ' goal of 45 ml/hr = 1620 kcals/ 73 g protein\n', ' 5. Will follow page [**Numeric Identifier 1372**] with questions\n', '"\n', '40461,Nutrition,"Subjective\n', ' Patient asleep, [**Name8 (MD) 77**] RN, patient refused all po food or supplements.\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 70.5 kg ([**2113-1-19**] 08:00 AM)\n', ' up due to fluid\n', ' 19.9\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 75.3 kg\n', ' 119%\n', ' 63 kg\n', ' 100%\n', ' Diagnosis: MITRAL VALVE ENDOCARDITIS\n', ' PMHx: None - no medical care x 30 years\n', ' Food allergies and intolerances: not available\n', ' Pertinent medications: Furosemide , Milrinone, Multivitamins, Thiamine,\n', ' FoLIC Acid, Nicotine Patch, Heparin, Docusate Sodium , Nafcillin,\n', ' Potassium Chloride, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 117 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' BUN\n', ' 25 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Creatinine\n', ' 1.5 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Sodium\n', ' 137 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Potassium\n', ' 3.3 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Chloride\n', ' 103 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' TCO2\n', ' 22 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' PO2 (venous)\n', ' 145 mm Hg\n', ' [**2113-1-15**] 04:51 PM\n', ' PCO2 (venous)\n', ' 34 mm Hg\n', ' [**2113-1-15**] 04:51 PM\n', ' pH (venous)\n', ' 7.45 units\n', ' [**2113-1-15**] 04:51 PM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2113-1-18**] 12:03 PM\n', ' CO2 (Calc) venous\n', ' 24 mEq/L\n', ' [**2113-1-15**] 04:51 PM\n', ' Albumin\n', ' 1.9 g/dL\n', ' [**2113-1-18**] 07:15 AM\n', ' Calcium non-ionized\n', ' 7.1 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Phosphorus\n', ' 4.8 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Magnesium\n', ' 1.9 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' ALT\n', ' 36 IU/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Alkaline Phosphate\n', ' 44 IU/L\n', ' [**2113-1-20**] 02:36 AM\n', ' AST\n', ' 54 IU/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Total Bilirubin\n', ' 0.4 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' WBC\n', ' 13.0 K/uL\n', ' [**2113-1-20**] 02:36 AM\n', ' Hgb\n', ' 11.8 g/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Hematocrit\n', ' 35.2 %\n', ' [**2113-1-20**] 02:36 AM\n', ' Current diet order / nutrition support: Regular; Supplement: Ensure\n', ' Plus breakfast, lunch, dinner\n', ' GI: Abdominal: Soft, Non-tender, Bowel sounds present\n', ' Extremities: Right lower extremity edema: Absent, Left lower extremity\n', ' edema\n', ' Skin: Warm, Rash: upper and lower ext, occ petechiae\n', ' Assessment of Nutritional Status\n', ' At risk for malnutrition\n', 'Patient at risk due to: Low po intake, current illness, head CT showed multipl\n', 'e small non-hemorrhagic\n', ' infarcts suspicious for septic emboli,\n', ' Estimated Nutritional Needs\n', ' Calories: 1575-1764 (BEE x or / 25-28 cal/kg)\n', ' Protein: 76-88 (1.2-1.4 g/kg)\n', ' Fluid: per team\n', ' Calculations based on: Admit weight\n', ' Estimation of previous intake: Inadequate\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' 49 year old male found to have staphylococcus aureus bacterial\n', ' endocarditis with severe mitral regurgitation [**3-21**] mitral valve\n', ' vegetations and flail leaflet. Patient transferred from [**Hospital **] [**Hospital1 5**] for CT surgery evaluation and further management.\n', ' Patient s/p speech and swallow evaluation, okay to have regular diet,\n', ' yet patient refused to take pos. spoke to team this morning, team\n', ' considering NGT placement.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Po as tolerance\n', ' Tube feeding recommendations: Nutren Pulmonary goal 45ml/hr\n', ' (1620kcal/73.4g protein)\n', ' Monitor tube feed tolerance\n', ' Check chemistry 10 panel daily, replete as you are doing\n', ' Consider adding phos binder if serum phos remains elevated\n', ' Start regular insulin sliding scale if serum glucose greater\n', ' than 150 mg/dL\n', ' Other: [**Numeric Identifier 943**] if has question\n', '"\n', '40461,Nutrition,"Subjective\n', ' Patient asleep, [**Name8 (MD) 77**] RN, patient refused all po food or supplements.\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 70.5 kg ([**2113-1-19**] 08:00 AM)\n', ' up due to fluid\n', ' 19.9\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 75.3 kg\n', ' 119%\n', ' 63 kg\n', ' 100%\n', ' Diagnosis: MITRAL VALVE ENDOCARDITIS\n', ' PMHx: None - no medical care x 30 years\n', ' Food allergies and intolerances: not available\n', ' Pertinent medications: Furosemide , Milrinone, Multivitamins, Thiamine,\n', ' FoLIC Acid, Nicotine Patch, Heparin, Docusate Sodium , Nafcillin,\n', ' Potassium Chloride, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 117 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' BUN\n', ' 25 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Creatinine\n', ' 1.5 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Sodium\n', ' 137 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Potassium\n', ' 3.3 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Chloride\n', ' 103 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' TCO2\n', ' 22 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' PO2 (venous)\n', ' 145 mm Hg\n', ' [**2113-1-15**] 04:51 PM\n', ' PCO2 (venous)\n', ' 34 mm Hg\n', ' [**2113-1-15**] 04:51 PM\n', ' pH (venous)\n', ' 7.45 units\n', ' [**2113-1-15**] 04:51 PM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2113-1-18**] 12:03 PM\n', ' CO2 (Calc) venous\n', ' 24 mEq/L\n', ' [**2113-1-15**] 04:51 PM\n', ' Albumin\n', ' 1.9 g/dL\n', ' [**2113-1-18**] 07:15 AM\n', ' Calcium non-ionized\n', ' 7.1 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Phosphorus\n', ' 4.8 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Magnesium\n', ' 1.9 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' ALT\n', ' 36 IU/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Alkaline Phosphate\n', ' 44 IU/L\n', ' [**2113-1-20**] 02:36 AM\n', ' AST\n', ' 54 IU/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Total Bilirubin\n', ' 0.4 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' WBC\n', ' 13.0 K/uL\n', ' [**2113-1-20**] 02:36 AM\n', ' Hgb\n', ' 11.8 g/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Hematocrit\n', ' 35.2 %\n', ' [**2113-1-20**] 02:36 AM\n', ' Current diet order / nutrition support: Regular; Supplement: Ensure\n', ' Plus breakfast, lunch, dinner\n', ' GI: Abdominal: Soft, Non-tender, Bowel sounds present\n', ' Extremities: Right lower extremity edema: Absent, Left lower extremity\n', ' edema\n', ' Skin: Warm, Rash: upper and lower ext, occ petechiae\n', ' Assessment of Nutritional Status\n', ' At risk for malnutrition\n', 'Patient at risk due to: Low po intake, current illness, head CT showed multipl\n', 'e small non-hemorrhagic\n', ' infarcts suspicious for septic emboli,\n', ' Estimated Nutritional Needs\n', ' Calories: 1575-1764 (BEE x or / 25-28 cal/kg)\n', ' Protein: 76-88 (1.2-1.4 g/kg)\n', ' Fluid: per team\n', ' Calculations based on: Admit weight\n', ' Estimation of previous intake: Inadequate\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' 49 year old male found to have staphylococcus aureus bacterial\n', ' endocarditis with severe mitral regurgitation [**3-21**] mitral valve\n', ' vegetations and flail leaflet. Patient transferred from [**Hospital **] [**Hospital1 5**] for CT surgery evaluation and further management.\n', ' Patient s/p speech and swallow evaluation, okay to have regular diet,\n', ' yet patient refused to take pos. spoke to team this morning, team\n', ' considering NGT placement.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Po as tolerance\n', ' Tube feeding recommendations: Nutren Pulmonary goal 45ml/hr\n', ' (1620kcal/73.4g protein)\n', ' Monitor tube feed tolerance\n', ' Check chemistry 10 panel daily, replete as you are doing\n', ' Consider adding phos binder if serum phos remains elevated\n', ' Start regular insulin sliding scale if serum glucose greater\n', ' than 150 mg/dL\n', ' Other: [**Numeric Identifier 943**] if has question\n', ' ------ Protected Section ------\n', ' Cardiology Teaching Physician Note\n', ' On this day I saw, examined and was physically present with the\n', ' resident / fellow for the key portions of the services provided. I\n', ' agree with the above note and plans.\n', ' I would add the following remarks:\n', ' Medical Decision Making\n', ' Patient slowly improving the am after aggressive diuresis and\n', ' initiation of Milrinone. He is less dyspneic and saturations are in the\n', ' 95-96% range. Renal service feels ARF is multifactorial and sediment is\n', ' c/w ATM. Createnine is stable today at 1.5. He is speaking clearly but\n', ' somnolent and wife, [**Name (NI) 1880**], feels this is from not sleeping last night.\n', ' WBC down to 13K from 14K yesterday. ID recommends continuing Nafcillin\n', ' with bllod cultures with fever spikes. Source of fevers are unclear now\n', ' and we may need to image his abdomen as he complains of intermittent\n', ' abdominal pain. C-[**Doctor First Name 91**] continues to follow closely and would like to\n', ' delay surgery for as long as possible.\n', ' ------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) **], MD\n', ' on:[**2113-1-20**] 05:48 PM ------\n', '"\n', '40461,Nutrition,"Subjective: Did not speak with patient.\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 72 kg ([**2113-1-22**] 10:00 AM)\n', ' 19.9\n', ' Pertinent medications: Milrinone, protonix, abx, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 98 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' BUN\n', ' 27 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Creatinine\n', ' 1.0 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Sodium\n', ' 137 mEq/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Potassium\n', ' 4.3 mEq/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Chloride\n', ' 107 mEq/L\n', ' [**2113-1-22**] 05:17 AM\n', ' TCO2\n', ' 19 mEq/L\n', ' [**2113-1-22**] 05:17 AM\n', ' PO2 (arterial)\n', ' 61 mm Hg\n', ' [**2113-1-22**] 12:22 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 31 mm Hg\n', ' [**2113-1-22**] 12:22 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.37 units\n', ' [**2113-1-22**] 12:22 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2113-1-20**] 06:24 PM\n', ' CO2 (Calc) arterial\n', ' 19 mEq/L\n', ' [**2113-1-22**] 12:22 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.1 g/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Calcium non-ionized\n', ' 7.6 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Phosphorus\n', ' 3.8 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Magnesium\n', ' 2.0 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' ALT\n', ' 27 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Alkaline Phosphate\n', ' 50 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' AST\n', ' 27 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Total Bilirubin\n', ' 0.3 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' WBC\n', ' 20.7 K/uL\n', ' [**2113-1-22**] 05:17 AM\n', ' Hgb\n', ' 12.9 g/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Hematocrit\n', ' 39.5 %\n', ' [**2113-1-22**] 05:17 AM\n', ' Current diet order / nutrition support: Diet: Regular/ heart healthy,\n', ' with ensure plus TID\n', ' GI: abd soft, bowel sounds present\n', ' Assessment of Nutritional Status\n', ' 49 year old male found to have staphylococcus aureus bacterial\n', ' endocarditis with severe mitral regurgitation [**3-21**] mitral valve\n', ' vegetations and flail leaflet. Patient transferred from [**Hospital **] to [**Hospital1 5**] for CT surgery evaluation and further management.\n', ' Patient s/p speech and swallow evaluation, okay to have regular diet,\n', ' yet patient is only taking small amounts of po\n', 's due to mental status.\n', ' Team is planning to place an NGT for start of tube feeds. Tube\n', ' feeding are recommendations below; these can be adjusted based on\n', ' amount of po\n', 's patient is taking.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' To meet 100% of estimated needs, recommend Nutren Pulmonary\n', ' @ 45mL/hr (1620kcals, 73g protein)\n', ' Will monitor po intake and mental status and adjust tube\n', ' feeds as needed.\n', ' Following g- #[**Numeric Identifier 1312**]\n', '"\n', '40461,Nutrition,"Subjective\n', ' intub\n', ' Objective\n', ' Pertinent medications: Multivitamins, FoLIC Acid , Pantoprazole,\n', ' Potassium Chloride, Norepinephrine drip, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 106 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' BUN\n', ' 15 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' Creatinine\n', ' 1.1 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' Sodium\n', ' 140 mEq/L\n', ' [**2113-1-25**] 03:36 AM\n', ' Potassium\n', ' 3.7 mEq/L\n', ' [**2113-1-25**] 03:36 AM\n', ' Chloride\n', ' 108 mEq/L\n', ' [**2113-1-25**] 03:36 AM\n', ' TCO2\n', ' 26 mEq/L\n', ' [**2113-1-25**] 03:36 AM\n', ' PO2 (arterial)\n', ' 108 mm Hg\n', ' [**2113-1-25**] 03:53 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 53 mm Hg\n', ' [**2113-1-25**] 03:53 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.32 units\n', ' [**2113-1-25**] 03:53 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2113-1-25**] 02:26 PM\n', ' CO2 (Calc) arterial\n', ' 29 mEq/L\n', ' [**2113-1-25**] 03:53 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.1 g/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Calcium non-ionized\n', ' 7.4 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' Phosphorus\n', ' 3.5 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' Magnesium\n', ' 1.6 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' ALT\n', ' 27 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Alkaline Phosphate\n', ' 50 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' AST\n', ' 27 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Amylase\n', ' 25 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Total Bilirubin\n', ' 0.3 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 11.4 K/uL\n', ' [**2113-1-25**] 03:36 AM\n', ' Hgb\n', ' 9.6 g/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' Hematocrit\n', ' 30.3 %\n', ' [**2113-1-25**] 03:36 AM\n', ' Current diet order / nutrition support: Nutren Pulmonary Full strength;\n', ' Additives: Banana flakes, 3 packets per day\n', ' Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 45 ml/hr\n', ' Residual Check: q4h Hold feeding for residual >= : 200 ml\n', ' Flush w/ 100 ml water q8h ( not running since 8 am this morning)\n', ' NPO for Procedure Start: After 12:01AM Procedure: CSURG on date\n', ' [**2113-1-26**]\n', ' Do NOT resume diet after procedure.\n', ' GI: Abd: soft, ND, NT, NBS\n', ' Ext: 2+ pulses, 2+ edema in lower extremtiies R>L\n', ' Assessment of Nutritional Status\n', ' 49 year old male found to have staphlyococcus aureus bacterial\n', ' endocarditis with severe mitral regurgitation [**3-21**] mitral valve\n', ' vegetations and flail leaflet, patient pending OR tomorrow for AVR and\n', ' MVR with debridement of the epidural abscess. Patient received minimal\n', ' nutrition since admission (had <24hours tube feed from 12/7-8), at very\n', ' high risk for malnutrition, recommend closely monitor post cardiac\n', ' surgery, may need to restart tube feed as patient was refusing all po\n', ' food this admission.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Multivitamin / Mineral supplement: discontinue outside order\n', ' if tube feed restarts\n', ' Tube feeding recommendations: restart tube feed as ordered\n', ' Check chemistry 10 panel daily, replete as you are doing\n', ' Start regular insulin sliding scale if serum glucose greater\n', ' than 150 mg/dL\n', ' Other: [**Numeric Identifier 943**] if has question\n', '"\n', '40461,Nutrition,"Ht: 70\n', ' Wt: 57.8 kg\n', ' IBW: 75.3 kg/ 77%\n', ' BMI: 18.2\n', ' Pmh: Diabetes,Dyslipidemia,Hypertension, [**1-25**] multiple embolic events\n', ' worst is large left posterior cerebral artery infarct(neurologic\n', ' deficits including left sided facial droop, right sided neglect, right\n', ' sided hemiparesis, expressive aphasia),\n', ' MVR(29mm St. [**Male First Name (un) 1104**] Mechanical Valve) with Debridement of Aortic Valve.\n', ' Teeth extraction [**2113-1-23**].\n', ' Diet Order: regular\n', ' 49 year old male was in rehab s/p M. Patient admitted to outside\n', ' hospital CT showed depressed fx of right frontal sinus. Patient\n', ' transferred\n', ' Potential for nutrition risk. Patient being monitored. Current\n', ' intervention if any, listed below:\n', ' Comments:\n', '"\n', '40461,Nutrition,"Ht: 70\n', ' Wt: 57.8 kg\n', ' IBW: 75.3 kg/ 77%\n', ' BMI: 18.2\n', ' Pmh: Diabetes,Dyslipidemia,Hypertension, [**1-25**] multiple embolic events\n', ' worst is large left posterior cerebral artery infarct(neurologic\n', ' deficits including left sided facial droop, right sided neglect, right\n', ' sided hemiparesis, expressive aphasia),\n', ' MVR(29mm St. [**Male First Name (un) 1104**] Mechanical Valve) with Debridement of Aortic Valve.\n', ' Teeth extraction [**2113-1-23**].\n', ' Diet Order: regular\n', ' 49 year old male on coumadin for a prosthetic mitral valve after\n', ' having Staphylococcal endocarditis of MV and AV, c/b multiple embolic\n', ' strokes admitted from rehab s/p fall. Patient tolerating diet no nausea\n', ' or vomiting. Patient reports much better po intake since admit to\n', ' [**Hospital1 5**]. Patient unsure of wt loss PTA and unsure of usual body wt. Will\n', ' add supplements to increase caloric intake.\n', ' Recommendations:\n', ' 1. Encourage pos and supplements\n', ' 2. Will add ensure TID\n', ' 3. Will follow page [**Numeric Identifier 1372**] with questions\n', '"\n', '40461,Nutrition,"Subjective\n', ' oriented x 1\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 72 kg ([**2113-2-1**] 04:00 AM)\n', ' 19.9\n', ' Pertinent medications: Ranitidine, ABX, Folic Acid, Thiamine,\n', ' Multi-vitamin, lasix, Colace (Held), KCl (20mEq repletion x3)\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 108 mg/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' Glucose Finger Stick\n', ' 124\n', ' [**2113-2-1**] 12:00 AM\n', ' BUN\n', ' 28 mg/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' Creatinine\n', ' 2.0 mg/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' Sodium\n', ' 139 mEq/L\n', ' [**2113-2-1**] 03:30 AM\n', ' Potassium\n', ' 3.7 mEq/L\n', ' [**2113-2-1**] 03:30 AM\n', ' Chloride\n', ' 105 mEq/L\n', ' [**2113-2-1**] 03:30 AM\n', ' TCO2\n', ' 23 mEq/L\n', ' [**2113-2-1**] 03:30 AM\n', ' PO2 (arterial)\n', ' 65 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 30 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2113-1-31**] 04:47 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.5 units\n', ' [**2113-2-1**] 07:16 AM\n', ' CO2 (Calc) arterial\n', ' 22 mEq/L\n', ' [**2113-1-31**] 04:47 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.2 g/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Calcium non-ionized\n', ' 7.6 mg/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' Phosphorus\n', ' 4.6 mg/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' Ionized Calcium\n', ' 1.08 mmol/L\n', ' [**2113-1-30**] 11:46 AM\n', ' Magnesium\n', ' 2.2 mg/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' ALT\n', ' 20 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Alkaline Phosphate\n', ' 57 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' AST\n', ' 26 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Amylase\n', ' 17 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Total Bilirubin\n', ' 0.4 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 18.2 K/uL\n', ' [**2113-2-1**] 03:30 AM\n', ' Hgb\n', ' 10.4 g/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' Hematocrit\n', ' 31.5 %\n', ' [**2113-2-1**] 03:30 AM\n', ' Current diet order / nutrition support: Diet: Ground solids, thin\n', ' liquids; Ensure Pudding and Carnation Instant Breakfast with meals;\n', ' calorie counts [**2-1**], [**2-2**], [**2-3**]\n', ' GI: soft, (+) bowel sounds; green liquid stool\n', ' Assessment of Nutritional Status\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' Patient s/p MVR / AVR [**1-27**]. Extubated [**1-30**]. Seen by SLP [**1-31**] who\n', ' recommended above altered consistency diet with 1:1 supervision. [**Name8 (MD) **]\n', ' RN, patient took Ensure pudding and some Carnation Instant Breakfast\n', ' shake this AM with a lot of encouragement. Patient takes very small\n', ' bites and is a picky eater. RN reports wife to bring in a list of\n', ' foods that patient likes. Calorie counts starting today. Concerned\n', ' with nutrition status given poor po\n', 's during admit (refusing po\n', 's at\n', ' times), only received tube feed briefly on/off and recent surgery.\n', ' Would strongly recommend supplemental tube feed to optimize nutrition\n', ' for post-op recovery.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Current diet / nutrition support is appropriate:\n', ' Encourage/assist with po\n', ' o Encourage wife to bring in food preference list or food\n', ' o Calorie counts\n', ' please record on kitchen receipt percent\n', ' eaten\n', ' Oral supplements: Continue as ordered\n', ' Multivitamin / Mineral supplement: continue current\n', ' Tube feeding recommendations:\n', ' o Consider placing NGT and beginning tube feeds to supplement\n', ' poor po\n', ' o Tube feed goal would be: Nutren Pulmonary @ 45ml/hr = 1620\n', ' calories and 73g protein\n', ' Check chemistry 10 panel daily\n', ' Will follow, page if questions *[**Numeric Identifier 606**]\n', '"\n', '40461,Nutrition,"Subjective\n', ' just extubated\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 76.2 kg ([**2113-1-30**] 04:00 AM)\n', ' 19.9\n', ' Pertinent medications: Multivitamins, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 106 mg/dL\n', ' [**2113-1-30**] 07:59 AM\n', ' Glucose Finger Stick\n', ' 93\n', ' [**2113-1-29**] 06:00 PM\n', ' BUN\n', ' 20 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Creatinine\n', ' 1.6 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Sodium\n', ' 137 mEq/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Potassium\n', ' 3.5 mEq/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Chloride\n', ' 104 mEq/L\n', ' [**2113-1-30**] 03:25 AM\n', ' TCO2\n', ' 22 mEq/L\n', ' [**2113-1-30**] 03:25 AM\n', ' PO2 (arterial)\n', ' 85.[**Numeric Identifier 299**] mm Hg\n', ' [**2113-1-30**] 09:19 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 33 mm Hg\n', ' [**2113-1-30**] 09:19 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.41 units\n', ' [**2113-1-30**] 09:19 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2113-1-25**] 02:26 PM\n', ' CO2 (Calc) arterial\n', ' 22 mEq/L\n', ' [**2113-1-30**] 09:19 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.2 g/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Calcium non-ionized\n', ' 8.4 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Phosphorus\n', ' 5.2 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Ionized Calcium\n', ' 1.09 mmol/L\n', ' [**2113-1-30**] 07:59 AM\n', ' Magnesium\n', ' 2.1 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' ALT\n', ' 20 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Alkaline Phosphate\n', ' 57 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' AST\n', ' 26 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Amylase\n', ' 17 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Total Bilirubin\n', ' 0.4 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 11.5 K/uL\n', ' [**2113-1-30**] 03:25 AM\n', ' Hgb\n', ' 10.3 g/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Hematocrit\n', ' 30.1 %\n', ' [**2113-1-30**] 03:25 AM\n', ' Current diet order / nutrition support: Nutren Pulmonary Full strength;\n', ' Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr\n', ' Residual Check: q4h Hold feeding for residual >= : 200 ml\n', ' Flush w/ 30 ml water q4h ( not running)\n', ' GI: soft, flesiseal in place\n', ' SKIN: stage 2 wounds\n', ' Assessment of Nutritional Status\n', ' 49 year old male admitted on [**1-15**] with endocarditis s/p MVR and aortic\n', ' valve debridement on [**1-27**], patient extubated this morning. Patient\n', ' well known to me from CCU, patient with minimal nutrition since\n', ' hospital admission (previously refused po food and nutrition\n', ' supplements in the ccu, received 1 day of tube feed prior to OR.\n', ' Patient at very high risk for malnutrition, highly recommend replace\n', ' feeding tube, restart tube feed as temporary nutrition support for post\n', ' op recovery.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Adv diet if remains medically stable\n', ' Continue tube feed as supplemental nutrition support: goal\n', ' Nutren Pulmonary goal 45ml/hr to provide 1620kcal/73.4g protein\n', ' Phos binder if serum phos remains elevated\n', ' Check chemistry 10 panel daily, replete prn\n', ' BS management\n', ' Other: [**Numeric Identifier 943**]\n', '"\n'] 2136
In [23]:
doc = []
for i in range(len(notes)):
doc.append(nlp(notes[i]))
print(doc[-1])
print('*************************************************************************************************************')
SUBJECT_ID,CATEGORY,TEXT
*************************************************************************************************************
17610,Nutrition,"Patient transferred to MICU for concern for aspiration. Diet changed
*************************************************************************************************************
to NPO; NGT in for medication. Noted plan to transition to comfort
*************************************************************************************************************
focused care.
*************************************************************************************************************
Will sign off at this time. Please consult if needed. Pager *[**Numeric Identifier 5307**]
*************************************************************************************************************
"
*************************************************************************************************************
40493,Nutrition,"Objective
*************************************************************************************************************
Pertinent medications: RISS, SS lytes, thiamin, folate, lasix, bowel
*************************************************************************************************************
regimen, MOM, reglan, others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
93 mg/dL
*************************************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
120
*************************************************************************************************************
[**2172-11-9**] 08:57 AM
*************************************************************************************************************
BUN
*************************************************************************************************************
15 mg/dL
*************************************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
0.6 mg/dL
*************************************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
137 mEq/L
*************************************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.9 mEq/L
*************************************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
106 mEq/L
*************************************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
24 mEq/L
*************************************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
66 mm Hg
*************************************************************************************************************
[**2172-11-9**] 08:57 AM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
41 mm Hg
*************************************************************************************************************
[**2172-11-9**] 08:57 AM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.42 units
*************************************************************************************************************
[**2172-11-9**] 08:57 AM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.0 units
*************************************************************************************************************
[**2172-11-1**] 06:06 PM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
28 mEq/L
*************************************************************************************************************
[**2172-11-9**] 08:57 AM
*************************************************************************************************************
Albumin
*************************************************************************************************************
2.6 g/dL
*************************************************************************************************************
[**2172-11-3**] 02:24 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
8.7 mg/dL
*************************************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
4.5 mg/dL
*************************************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************************************
Ionized Calcium
*************************************************************************************************************
1.11 mmol/L
*************************************************************************************************************
[**2172-11-5**] 01:34 PM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
2.2 mg/dL
*************************************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************************************
Current diet order / nutrition support: Fibersource HN@60mL/hr (1728
*************************************************************************************************************
kcals/73 gr aa) not infusing
*************************************************************************************************************
GI: Abd soft/+bs
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
Specifics:
*************************************************************************************************************
Pt extubated earlier today. Pt was previously tolerating TF
*************************************************************************************************************
s @ goal,
*************************************************************************************************************
meeting 100% estimated nutrition needs. Anticipate diet advancement as
*************************************************************************************************************
able.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
Advance diet per team c/ swallow eval if pt shows s/s of aspiration and
*************************************************************************************************************
advance diet per SLP- vs place NGT and resume TF's if unable to take
*************************************************************************************************************
po
*************************************************************************************************************
Will follow plan -please page c/ ?'s #[**Numeric Identifier 1684**]
*************************************************************************************************************
"
*************************************************************************************************************
40493,Nutrition,"Subjective
*************************************************************************************************************
intubated
*************************************************************************************************************
Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
168 cm
*************************************************************************************************************
65 kg
*************************************************************************************************************
23.1
*************************************************************************************************************
Ideal body weight
*************************************************************************************************************
% Ideal body weight
*************************************************************************************************************
Adjusted weight
*************************************************************************************************************
Usual body weight
*************************************************************************************************************
% Usual body weight
*************************************************************************************************************
64.4 kg
*************************************************************************************************************
101%
*************************************************************************************************************
Diagnosis: S/P Fall
*************************************************************************************************************
PMH : etoh, smoker, cirrhosis
*************************************************************************************************************
Food allergies and intolerances: NKFA
*************************************************************************************************************
Pertinent medications: fentanyl, LR @ 10 ml/hr, lasix, versed, RISS, IV
*************************************************************************************************************
abx, others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
155 mg/dL
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
151
*************************************************************************************************************
[**2172-11-2**] 08:00 AM
*************************************************************************************************************
BUN
*************************************************************************************************************
17 mg/dL
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
0.8 mg/dL
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Sodium
*************************************************************************************************************
146 mEq/L
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.6 mEq/L
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Chloride
*************************************************************************************************************
111 mEq/L
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
TCO2
*************************************************************************************************************
29 mEq/L
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
113 mm Hg
*************************************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
41 mm Hg
*************************************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.46 units
*************************************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.0 units
*************************************************************************************************************
[**2172-11-1**] 06:06 PM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
30 mEq/L
*************************************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************************************
Albumin
*************************************************************************************************************
3.0 g/dL
*************************************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
8.1 mg/dL
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
2.5 mg/dL
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Ionized Calcium
*************************************************************************************************************
1.16 mmol/L
*************************************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
1.7 mg/dL
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
ALT
*************************************************************************************************************
14 IU/L
*************************************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************************************
Alkaline Phosphate
*************************************************************************************************************
73 IU/L
*************************************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************************************
AST
*************************************************************************************************************
43 IU/L
*************************************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************************************
Total Bilirubin
*************************************************************************************************************
3.4 mg/dL
*************************************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
23.2 K/uL
*************************************************************************************************************
[**2172-11-2**] 01:06 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
9.1 g/dL
*************************************************************************************************************
[**2172-11-2**] 01:06 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
27.2 %
*************************************************************************************************************
[**2172-11-2**] 01:06 AM
*************************************************************************************************************
Current diet order / nutrition support: NPO replete with fiber @ 60
*************************************************************************************************************
ml/hr
*************************************************************************************************************
GI: OGT
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
At risk for malnutrition
*************************************************************************************************************
Pt at risk due to: NPO / hypocaloric diet
*************************************************************************************************************
Estimated Nutritional Needs
*************************************************************************************************************
Calories: 1625-[**2114**] (25-30 cal/kg)
*************************************************************************************************************
Protein: 78-91 (1.2-1.4 g/kg)
*************************************************************************************************************
Fluid: per team
*************************************************************************************************************
Estimation of previous intake: Likely Adequate
*************************************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************************************
Specifics: 57 year old male transferred from OSH, intubated there. Pt
*************************************************************************************************************
S/P fall CT shows Stage IV splenic laceration. Tolerating TF with
*************************************************************************************************************
minimal residuals [**Name8 (MD) **] RN. Current TF provides 1440 kcals/89 g Pro.
*************************************************************************************************************
Recommend changing TF to better meet nutritional needs.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
1. Check chemistry 10 panel daily
*************************************************************************************************************
2. Change TF to goal of Fibersource HN @ 65ml/hr (1872 kcals/83 g
*************************************************************************************************************
Pro)
*************************************************************************************************************
3. Pls page with questions [**Numeric Identifier 2584**]
*************************************************************************************************************
"
*************************************************************************************************************
40493,Nutrition,"Subjective
*************************************************************************************************************
intubated
*************************************************************************************************************
Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
168 cm
*************************************************************************************************************
65 kg
*************************************************************************************************************
23.1
*************************************************************************************************************
Ideal body weight
*************************************************************************************************************
% Ideal body weight
*************************************************************************************************************
Adjusted weight
*************************************************************************************************************
Usual body weight
*************************************************************************************************************
% Usual body weight
*************************************************************************************************************
64.4 kg
*************************************************************************************************************
101%
*************************************************************************************************************
Diagnosis: S/P Fall
*************************************************************************************************************
PMH : etoh, smoker, cirrhosis
*************************************************************************************************************
Food allergies and intolerances: NKFA
*************************************************************************************************************
Pertinent medications: fentanyl, LR @ 10 ml/hr, lasix, versed, RISS, IV
*************************************************************************************************************
abx, others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
155 mg/dL
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
151
*************************************************************************************************************
[**2172-11-2**] 08:00 AM
*************************************************************************************************************
BUN
*************************************************************************************************************
17 mg/dL
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
0.8 mg/dL
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Sodium
*************************************************************************************************************
146 mEq/L
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.6 mEq/L
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Chloride
*************************************************************************************************************
111 mEq/L
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
TCO2
*************************************************************************************************************
29 mEq/L
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
113 mm Hg
*************************************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
41 mm Hg
*************************************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.46 units
*************************************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.0 units
*************************************************************************************************************
[**2172-11-1**] 06:06 PM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
30 mEq/L
*************************************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************************************
Albumin
*************************************************************************************************************
3.0 g/dL
*************************************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
8.1 mg/dL
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
2.5 mg/dL
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
Ionized Calcium
*************************************************************************************************************
1.16 mmol/L
*************************************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
1.7 mg/dL
*************************************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************************************
ALT
*************************************************************************************************************
14 IU/L
*************************************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************************************
Alkaline Phosphate
*************************************************************************************************************
73 IU/L
*************************************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************************************
AST
*************************************************************************************************************
43 IU/L
*************************************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************************************
Total Bilirubin
*************************************************************************************************************
3.4 mg/dL
*************************************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
23.2 K/uL
*************************************************************************************************************
[**2172-11-2**] 01:06 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
9.1 g/dL
*************************************************************************************************************
[**2172-11-2**] 01:06 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
27.2 %
*************************************************************************************************************
[**2172-11-2**] 01:06 AM
*************************************************************************************************************
Current diet order / nutrition support: NPO replete with fiber @ 60
*************************************************************************************************************
ml/hr
*************************************************************************************************************
GI: OGT
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
At risk for malnutrition
*************************************************************************************************************
Pt at risk due to: NPO / hypocaloric diet
*************************************************************************************************************
Estimated Nutritional Needs
*************************************************************************************************************
Calories: 1625-[**2114**] (25-30 cal/kg)
*************************************************************************************************************
Protein: 78-91 (1.2-1.4 g/kg)
*************************************************************************************************************
Fluid: per team
*************************************************************************************************************
Estimation of previous intake: Likely Adequate
*************************************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************************************
Specifics: 57 year old male transferred from OSH, intubated there. Pt
*************************************************************************************************************
S/P fall CT shows Stage IV splenic laceration. Tolerating TF with
*************************************************************************************************************
minimal residuals [**Name8 (MD) **] RN. Current TF provides 1440 kcals/89 g Pro.
*************************************************************************************************************
Recommend changing TF to better meet nutritional needs.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
1. Check chemistry 10 panel daily
*************************************************************************************************************
2. Change TF to goal of Fibersource HN @ 65ml/hr (1872 kcals/83 g
*************************************************************************************************************
Pro)
*************************************************************************************************************
3. Pls page with questions [**Numeric Identifier 2584**]
*************************************************************************************************************
"
*************************************************************************************************************
61565,Nutrition,"Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
178 cm
*************************************************************************************************************
88.2 kg
*************************************************************************************************************
27.8
*************************************************************************************************************
Ideal body weight
*************************************************************************************************************
% Ideal body weight
*************************************************************************************************************
Adjusted weight
*************************************************************************************************************
Usual body weight
*************************************************************************************************************
% Usual body weight
*************************************************************************************************************
75.3 kg
*************************************************************************************************************
117%
*************************************************************************************************************
Diagnosis: Head Bleed
*************************************************************************************************************
PMH : DM.
*************************************************************************************************************
Food allergies and intolerances:
*************************************************************************************************************
Pertinent medications: Esmolol, famotidine, colace, lytes ss, dilantin,
*************************************************************************************************************
ssri, others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
143 mg/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
155
*************************************************************************************************************
[**2100-11-1**] 02:00 AM
*************************************************************************************************************
BUN
*************************************************************************************************************
18 mg/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
0.8 mg/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
142 mEq/L
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
4.1 mEq/L
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
111 mEq/L
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
26 mEq/L
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
109 mm Hg
*************************************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
38 mm Hg
*************************************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.48 units
*************************************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
29 mEq/L
*************************************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************************************
Albumin
*************************************************************************************************************
3.8 g/dL
*************************************************************************************************************
[**2100-10-30**] 03:27 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
8.9 mg/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
2.5 mg/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Ionized Calcium
*************************************************************************************************************
1.22 mmol/L
*************************************************************************************************************
[**2100-10-31**] 02:41 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
2.3 mg/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Phenytoin (Dilantin)
*************************************************************************************************************
10.1 ug/mL
*************************************************************************************************************
[**2100-10-31**] 02:34 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
12.1 K/uL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
11.9 g/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
33.9 %
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Current diet order / nutrition support: Replete with fiber Full
*************************************************************************************************************
strength; Goal rate: 65 ml/hr
*************************************************************************************************************
Residual Check: q4h Hold feeding for residual >= : 200 ml
*************************************************************************************************************
GI:
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
At risk for malnutrition
*************************************************************************************************************
Pt at risk due to: NPO / hypocaloric diet
*************************************************************************************************************
Estimated Nutritional Needs
*************************************************************************************************************
Calories: [**2027**]-2200 (BEE x or / 22-25 cal/kg)
*************************************************************************************************************
Protein: 114 (1.3 g/kg)
*************************************************************************************************************
Fluid:
*************************************************************************************************************
Estimation of previous intake: Adequate
*************************************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************************************
Specifics:
*************************************************************************************************************
72 yo male s/p witnessed fall w/ head trauma, right parietal-occipital
*************************************************************************************************************
SAH w/ left intraparenchymal bleed / contre-coup injury. Pt started on
*************************************************************************************************************
TF yesterday, currently tol goal TF without issue, per chart, pt with +
*************************************************************************************************************
gag, will plan to extubate this am. If unable to extubate, will need
*************************************************************************************************************
to change TF to better meet pt's needs.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
Tube feeding recommendations:
*************************************************************************************************************
Check chemistry 10 panel daily and replete
*************************************************************************************************************
Cont Bg management
*************************************************************************************************************
Pplease page [**Numeric Identifier 1550**] if has ?
*************************************************************************************************************
"
*************************************************************************************************************
61565,Nutrition,"Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
178 cm est.
*************************************************************************************************************
88.2 kg
*************************************************************************************************************
27.8
*************************************************************************************************************
Ideal body weight
*************************************************************************************************************
% Ideal body weight
*************************************************************************************************************
Adjusted weight
*************************************************************************************************************
Usual body weight
*************************************************************************************************************
% Usual body weight
*************************************************************************************************************
75.3 kg
*************************************************************************************************************
117%
*************************************************************************************************************
Diagnosis: Head Bleed
*************************************************************************************************************
PMH : DM, HTN
*************************************************************************************************************
Food allergies and intolerances:
*************************************************************************************************************
Pertinent medications: Esmolol, famotidine, colace, lytes ss, dilantin,
*************************************************************************************************************
ssri, others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
143 mg/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
155
*************************************************************************************************************
[**2100-11-1**] 02:00 AM
*************************************************************************************************************
BUN
*************************************************************************************************************
18 mg/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
0.8 mg/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
142 mEq/L
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
4.1 mEq/L
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
111 mEq/L
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
26 mEq/L
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
109 mm Hg
*************************************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
38 mm Hg
*************************************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.48 units
*************************************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
29 mEq/L
*************************************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************************************
Albumin
*************************************************************************************************************
3.8 g/dL
*************************************************************************************************************
[**2100-10-30**] 03:27 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
8.9 mg/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
2.5 mg/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Ionized Calcium
*************************************************************************************************************
1.22 mmol/L
*************************************************************************************************************
[**2100-10-31**] 02:41 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
2.3 mg/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Phenytoin (Dilantin)
*************************************************************************************************************
10.1 ug/mL
*************************************************************************************************************
[**2100-10-31**] 02:34 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
12.1 K/uL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
11.9 g/dL
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
33.9 %
*************************************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************************************
Current diet order / nutrition support: Replete with fiber Full
*************************************************************************************************************
strength; Goal rate: 65 ml/hr (1560kcal/96.7g pro)
*************************************************************************************************************
Residual Check: q4h Hold feeding for residual >= : 200 ml
*************************************************************************************************************
GI: Soft, Non-distended, Non-tender
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
At risk for malnutrition
*************************************************************************************************************
Pt at risk due to: NPO
*************************************************************************************************************
Estimated Nutritional Needs
*************************************************************************************************************
Calories: 1760-2200 (BEE x or / 20-25 cal/kg)
*************************************************************************************************************
Protein: 114 (1.3 g/kg)
*************************************************************************************************************
Fluid: per team
*************************************************************************************************************
Estimation of previous intake: likely adequate
*************************************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************************************
Specifics:
*************************************************************************************************************
72 yo male s/p witnessed fall w/ head trauma, right parietal-occipital
*************************************************************************************************************
SAH w/ left intraparenchymal bleed / contre-coup injury. Pt started on
*************************************************************************************************************
TF yesterday, currently tol goal TF without issue, per chart, pt with +
*************************************************************************************************************
gag, cough, [**Last Name (LF) 1080**], [**First Name3 (LF) **] plan to extubate this am. If unable to
*************************************************************************************************************
extubate, will need to change TF to better meet pt's needs.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
Tube feeding recommendations: increase TF to Replete with Fiber goal
*************************************************************************************************************
75ml/hr (1800kcal/112g pro)
*************************************************************************************************************
Check chemistry 10 panel daily and replete prn
*************************************************************************************************************
Cont Bg management
*************************************************************************************************************
Please page [**Numeric Identifier 1550**] if has ?
*************************************************************************************************************
"
*************************************************************************************************************
61565,Nutrition,"Objective
*************************************************************************************************************
Pertinent medications: pepcid, Heparin, docusate, Abx, RISS, others
*************************************************************************************************************
noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
128 mg/dL
*************************************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
140
*************************************************************************************************************
[**2100-11-4**] 08:00 PM
*************************************************************************************************************
BUN
*************************************************************************************************************
18 mg/dL
*************************************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
0.7 mg/dL
*************************************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
140 mEq/L
*************************************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.9 mEq/L
*************************************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
103 mEq/L
*************************************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
28 mEq/L
*************************************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
94.[**Numeric Identifier 126**] mm Hg
*************************************************************************************************************
[**2100-11-5**] 07:26 AM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
37 mm Hg
*************************************************************************************************************
[**2100-11-5**] 07:26 AM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.49 units
*************************************************************************************************************
[**2100-11-5**] 07:26 AM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
7.0 units
*************************************************************************************************************
[**2100-11-5**] 11:05 AM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
29 mEq/L
*************************************************************************************************************
[**2100-11-5**] 07:26 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
8.7 mg/dL
*************************************************************************************************************
[**2100-11-4**] 02:31 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
3.0 mg/dL
*************************************************************************************************************
[**2100-11-4**] 02:31 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
2.3 mg/dL
*************************************************************************************************************
[**2100-11-4**] 02:31 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
12.2 K/uL
*************************************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
12.0 g/dL
*************************************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
33.8 %
*************************************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************************************
Current diet order / nutrition support: Replete c/ Fiber @65mL/hr (1560
*************************************************************************************************************
kcals/97 gr aa)
*************************************************************************************************************
GI: Abd: soft/+bs
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************************************
Specifics:
*************************************************************************************************************
Pt s/p trach/PEG/and IVC filter yesterday. TF
*************************************************************************************************************
s currently infusing @
*************************************************************************************************************
10mL/hr. Current goal Rx will meet 88% estimated kcal and 85% estimated
*************************************************************************************************************
aa needs therefore, will need to increase goal rate of TF
*************************************************************************************************************
s to avoid
*************************************************************************************************************
underfeeding. .
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
Multivitamin / Mineral supplement: vua TF
*************************************************************************************************************
Tube feeding recommendations: Increase TF goal rate to 75 mL/hr (1800
*************************************************************************************************************
kcals/112 gr aa)
*************************************************************************************************************
BG management as you are
*************************************************************************************************************
Please page c/?'s #[**Numeric Identifier 1684**]
*************************************************************************************************************
"
*************************************************************************************************************
98851,Nutrition,"Patient has been NPO and/or on unsupplemented clear liquid diet for 1
*************************************************************************************************************
days. If patient's diet is not able to be advanced and tolerated,
*************************************************************************************************************
[**Street Address(1) 1511**] for nutrition support
*************************************************************************************************************
Potential for nutrition risk. Patient being monitored. Current
*************************************************************************************************************
intervention if any, listed below:
*************************************************************************************************************
Comments:
*************************************************************************************************************
Pt s/p LRRT [**4-17**], c/b hypoxia and increased O2 requirements in PACU, on
*************************************************************************************************************
clears, tolerating well. Clinically improving, possibly transfer to
*************************************************************************************************************
floor soon.
*************************************************************************************************************
If unable to advance diet further in 24-48hrs, patient may benefit from
*************************************************************************************************************
nutrition support.
*************************************************************************************************************
Will f/u with progress, po tolerance.
*************************************************************************************************************
Please page w/ questions #[**Numeric Identifier 1687**]
*************************************************************************************************************
12:11
*************************************************************************************************************
"
*************************************************************************************************************
58054,Nutrition,"Comments:
*************************************************************************************************************
Screening per hospital nutrition protocol. Noted patient is comfort
*************************************************************************************************************
measures only. No nutrition support indicated at this time. Will sign
*************************************************************************************************************
off. Please consult if needed. #[**Numeric Identifier 2337**]
*************************************************************************************************************
"
*************************************************************************************************************
99573,Nutrition,"Subjective
*************************************************************************************************************
patient confused, unable to answer questions per chart patient had
*************************************************************************************************************
difficulty swallowing PTA d/t damaged salivary glands from XRT
*************************************************************************************************************
Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
168 cm
*************************************************************************************************************
98.2 kg
*************************************************************************************************************
34.9
*************************************************************************************************************
Ideal body weight
*************************************************************************************************************
% Ideal body weight
*************************************************************************************************************
Adjusted weight
*************************************************************************************************************
Usual body weight
*************************************************************************************************************
% Usual body weight
*************************************************************************************************************
59 kg
*************************************************************************************************************
166%
*************************************************************************************************************
68.8 kg
*************************************************************************************************************
Diagnosis: facial fx
*************************************************************************************************************
PMH : breast ca, tongue ca, ovarian ca, polymyalgia, NIDDM, vertigo, hx
*************************************************************************************************************
of falls
*************************************************************************************************************
Food allergies and intolerances: none noted
*************************************************************************************************************
Pertinent medications: RISS, IV abx, protonix, KCl (30 mEq), Dextrose
*************************************************************************************************************
5% 1/2 normal saline with KCl, others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
206
*************************************************************************************************************
[**2181-6-5**] 08:00 AM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
222
*************************************************************************************************************
[**2181-6-4**] 08:00 PM
*************************************************************************************************************
BUN
*************************************************************************************************************
11 mg/dL
*************************************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
0.5 mg/dL
*************************************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************************************
Sodium
*************************************************************************************************************
134 mEq/L
*************************************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************************************
Potassium
*************************************************************************************************************
4.1 mEq/L
*************************************************************************************************************
[**2181-6-5**] 09:13 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
98 mEq/L
*************************************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************************************
TCO2
*************************************************************************************************************
26 mEq/L
*************************************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
6.5 units
*************************************************************************************************************
[**2181-6-3**] 12:30 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
8.5 mg/dL
*************************************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
2.3 mg/dL
*************************************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
2.0 mg/dL
*************************************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************************************
WBC
*************************************************************************************************************
9.2 K/uL
*************************************************************************************************************
[**2181-6-5**] 12:03 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
10.9 g/dL
*************************************************************************************************************
[**2181-6-5**] 12:03 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
32.7 %
*************************************************************************************************************
[**2181-6-5**] 12:03 AM
*************************************************************************************************************
Current diet order / nutrition support: NPO
*************************************************************************************************************
GI: obese, + bowel sounds
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
Obese, At risk for malnutrition
*************************************************************************************************************
Pt at risk due to: NPO / hypocaloric diet, trauma
*************************************************************************************************************
Estimated Nutritional Needs based on adjusted body wt
*************************************************************************************************************
Calories: 1513-1720 (22-25 cal/kg)
*************************************************************************************************************
Protein: 83-103 (1.2-1.5 g/kg)
*************************************************************************************************************
Fluid: per team
*************************************************************************************************************
Estimation of previous intake: unknown
*************************************************************************************************************
Estimation of current intake: Inadequate d/t NPO status
*************************************************************************************************************
Specifics: 78 year old female admitted from outside hospital S/P fall
*************************************************************************************************************
at home with multiple injuries including Le Forte fx, multiple sinus
*************************************************************************************************************
fx, orbital fx, facial and tongue swelling. Patient seen by SLP on [**6-4**]
*************************************************************************************************************
who recommended patient remain NPO. If patient
*************************************************************************************************************
s diet cannot be
*************************************************************************************************************
advanced consider initiating tube feedings to prevent further
*************************************************************************************************************
nutritional decline.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
If diet cannot be advanced recommend starting tube feedings start with
*************************************************************************************************************
Replete with Fiber @ 15 ml/hr advance to goal of 65 ml/hr =1560
*************************************************************************************************************
kcals/97 g protein
*************************************************************************************************************
Check residuals q 4-6 hours hold if greater than 150 cc
*************************************************************************************************************
Monitor lytes and glucose with initiation of tube feeding
*************************************************************************************************************
Change to non-dextrose IV fluids once tube feedings started
*************************************************************************************************************
Implement any SLP recs
*************************************************************************************************************
Will continue to follow page [**Numeric Identifier 1372**] with questions
*************************************************************************************************************
"
*************************************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************************************
oriented x1
*************************************************************************************************************
Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
178 cm
*************************************************************************************************************
63 kg
*************************************************************************************************************
74.9 kg ([**2113-2-3**] 04:00 AM)
*************************************************************************************************************
19.9
*************************************************************************************************************
Pertinent medications: Ranitidine, Multi-vitamin, ABX, Folic Acid,
*************************************************************************************************************
Thiamine, Coumadin, Lasix, Colace (held), KCl (20mEq repletion x2),
*************************************************************************************************************
Magnesium sulfate (2g repletion), Heparin drip
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
105 mg/dL
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
127
*************************************************************************************************************
[**2113-2-3**] 12:00 PM
*************************************************************************************************************
BUN
*************************************************************************************************************
25 mg/dL
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
1.8 mg/dL
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
142 mEq/L
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.9 mEq/L
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
110 mEq/L
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
25 mEq/L
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
65 mm Hg
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
PO2 (venous)
*************************************************************************************************************
48 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
30 mm Hg
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
PCO2 (venous)
*************************************************************************************************************
33 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.46 units
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
pH (venous)
*************************************************************************************************************
7.43 units
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.5 units
*************************************************************************************************************
[**2113-2-1**] 07:16 AM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
22 mEq/L
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
CO2 (Calc) venous
*************************************************************************************************************
23 mEq/L
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
Albumin
*************************************************************************************************************
2.1 g/dL
*************************************************************************************************************
[**2113-2-1**] 02:44 PM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
7.5 mg/dL
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
3.0 mg/dL
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Ionized Calcium
*************************************************************************************************************
1.08 mmol/L
*************************************************************************************************************
[**2113-1-30**] 11:46 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
2.3 mg/dL
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
ALT
*************************************************************************************************************
23 IU/L
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Alkaline Phosphate
*************************************************************************************************************
51 IU/L
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
AST
*************************************************************************************************************
24 IU/L
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Amylase
*************************************************************************************************************
40 IU/L
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Total Bilirubin
*************************************************************************************************************
0.3 mg/dL
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Triglyceride
*************************************************************************************************************
120 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
9.3 K/uL
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
8.9 g/dL
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
27.0 %
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Current diet order / nutrition support: Diet: NPO
*************************************************************************************************************
Calorie counts: [**2-1**] - 17 - 18
*************************************************************************************************************
GI: soft, (+) bowel sounds; 500ml stool today
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************************************
Specifics:
*************************************************************************************************************
49 year old male with mitral valve endocarditis, preop stroke s/p MVR
*************************************************************************************************************
(29mm [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1104**] [**Last Name (NamePattern1) 1105**]) debridement of aortic valve [**1-27**]. Patient with
*************************************************************************************************************
prolonged poor po
*************************************************************************************************************
s during admit. Was on ground solids + thin liquid
*************************************************************************************************************
diet, refusing po
*************************************************************************************************************
s at times. s/p calories counts
*************************************************************************************************************
880 calories [**2-1**]
*************************************************************************************************************
and 270 calories [**2-2**]. Seen for video swallow evaluation this AM
*************************************************************************************************************
SLP recommend NPO. Per discussion with PA
*************************************************************************************************************
plan for PEG placement as
*************************************************************************************************************
previously unable to place NGT and feel that patient will pull it out.
*************************************************************************************************************
Agree with PEG for long term nutrition support to prevent further
*************************************************************************************************************
nutritional decline and optimize nutrition for post-op healing. Noted
*************************************************************************************************************
multiple lyte repletions.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
Current diet / nutrition support is appropriate: continue
*************************************************************************************************************
NPO per SLP recommendations
*************************************************************************************************************
o SLP follow up when appropriate
*************************************************************************************************************
Tube feeding recommendations: Agree with PEG
*************************************************************************************************************
o Once feeding tube placed, recommend begin Isosource 1.5 @
*************************************************************************************************************
20ml/hr, advance as tolerated to goal of 45ml/hr = 1620 calories and
*************************************************************************************************************
73g protein
*************************************************************************************************************
Check residuals, hold tube feed if greater than 200ml
*************************************************************************************************************
Multivitamin / Mineral supplement: continue current
*************************************************************************************************************
Check chemistry 10 panel daily
*************************************************************************************************************
o Replete lytes PRN
*************************************************************************************************************
Will follow, page if questions *[**Numeric Identifier 606**]
*************************************************************************************************************
"
*************************************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************************************
Patient oob, tube feed running at 40 ml/hr.
*************************************************************************************************************
Objective
*************************************************************************************************************
Pertinent medications: noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
119
*************************************************************************************************************
[**2113-2-8**] 08:00 AM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
150
*************************************************************************************************************
[**2113-2-7**] 10:00 PM
*************************************************************************************************************
BUN
*************************************************************************************************************
31 mg/dL
*************************************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
2.0 mg/dL
*************************************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
143 mEq/L
*************************************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.4 mEq/L
*************************************************************************************************************
[**2113-2-8**] 07:52 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
109 mEq/L
*************************************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
25 mEq/L
*************************************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
65 mm Hg
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
PO2 (venous)
*************************************************************************************************************
48 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
30 mm Hg
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
PCO2 (venous)
*************************************************************************************************************
33 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.46 units
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
pH (venous)
*************************************************************************************************************
7.43 units
*************************************************************************************************************
[**2113-2-7**] 05:19 PM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.5 units
*************************************************************************************************************
[**2113-2-1**] 07:16 AM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
22 mEq/L
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
CO2 (Calc) venous
*************************************************************************************************************
23 mEq/L
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
Albumin
*************************************************************************************************************
2.2 g/dL
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
7.8 mg/dL
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
4.0 mg/dL
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Ionized Calcium
*************************************************************************************************************
1.07 mmol/L
*************************************************************************************************************
[**2113-2-7**] 05:19 PM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
2.1 mg/dL
*************************************************************************************************************
[**2113-2-8**] 07:52 AM
*************************************************************************************************************
ALT
*************************************************************************************************************
21 IU/L
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Alkaline Phosphate
*************************************************************************************************************
50 IU/L
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
AST
*************************************************************************************************************
23 IU/L
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Amylase
*************************************************************************************************************
45 IU/L
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Total Bilirubin
*************************************************************************************************************
0.4 mg/dL
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Triglyceride
*************************************************************************************************************
120 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
10.1 K/uL
*************************************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
8.3 g/dL
*************************************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
26.1 %
*************************************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************************************
Current diet order / nutrition support: Replete with fiber Full
*************************************************************************************************************
strength;
*************************************************************************************************************
Starting rate: 40 ml/hr; Advance rate by 20 ml q6h Goal rate: 70 ml/hr
*************************************************************************************************************
Residual Check: q4h Hold feeding for residual >= : 200 ml
*************************************************************************************************************
Flush w/ 30 ml water q8h
*************************************************************************************************************
GI: Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,
*************************************************************************************************************
PEG site clean and dry.
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
49 year old male s/p PEG placement yesterday, tube feed started
*************************************************************************************************************
yesterday, tolerated Isosource 1.5 well, tube feed ordered changed to
*************************************************************************************************************
Replete with fiber this morning, spoke to team, does not want patient
*************************************************************************************************************
on special tube feed, recommend change to Fibersource HN as current
*************************************************************************************************************
formula provides excess amount of protein. Noted discharge planning in
*************************************************************************************************************
progress.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
Tube feeding: Fibersource HN goal 60ml/hr ( 1728kcal/76g
*************************************************************************************************************
protein)
*************************************************************************************************************
Check chemistry 10 panel daily, replete prn
*************************************************************************************************************
Continue BS management
*************************************************************************************************************
[**Numeric Identifier 943**] if has question
*************************************************************************************************************
"
*************************************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************************************
Patient asleep.
*************************************************************************************************************
Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
178 cm
*************************************************************************************************************
63 kg
*************************************************************************************************************
70.8 kg ([**2113-2-7**] 04:00 AM)
*************************************************************************************************************
19.9
*************************************************************************************************************
Pertinent medications: Multiple Vitamins, Furosemide, Docusate Sodium,
*************************************************************************************************************
others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
157 mg/dL
*************************************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
158
*************************************************************************************************************
[**2113-2-7**] 06:00 AM
*************************************************************************************************************
BUN
*************************************************************************************************************
33 mg/dL
*************************************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
1.9 mg/dL
*************************************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
145 mEq/L
*************************************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.7 mEq/L
*************************************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
111 mEq/L
*************************************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
24 mEq/L
*************************************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
65 mm Hg
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
PO2 (venous)
*************************************************************************************************************
48 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
30 mm Hg
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
PCO2 (venous)
*************************************************************************************************************
33 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.46 units
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
pH (venous)
*************************************************************************************************************
7.43 units
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.5 units
*************************************************************************************************************
[**2113-2-1**] 07:16 AM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
22 mEq/L
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
CO2 (Calc) venous
*************************************************************************************************************
23 mEq/L
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
Albumin
*************************************************************************************************************
2.2 g/dL
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
7.8 mg/dL
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
4.0 mg/dL
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Ionized Calcium
*************************************************************************************************************
1.08 mmol/L
*************************************************************************************************************
[**2113-1-30**] 11:46 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
2.0 mg/dL
*************************************************************************************************************
[**2113-2-6**] 11:00 PM
*************************************************************************************************************
ALT
*************************************************************************************************************
21 IU/L
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Alkaline Phosphate
*************************************************************************************************************
50 IU/L
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
AST
*************************************************************************************************************
23 IU/L
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Amylase
*************************************************************************************************************
45 IU/L
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Total Bilirubin
*************************************************************************************************************
0.4 mg/dL
*************************************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************************************
Triglyceride
*************************************************************************************************************
120 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
12.3 K/uL
*************************************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
8.8 g/dL
*************************************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
26.9 %
*************************************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************************************
Current diet order / nutrition support: Non-Standard TPN For Date:
*************************************************************************************************************
[**2113-2-6**] (1600ml, 270drextrose/80protein/35fat)
*************************************************************************************************************
Replete with fiber Full strength;
*************************************************************************************************************
Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 60 ml/hr
*************************************************************************************************************
Residual Check: q4h Hold feeding for residual >= : 200 ml
*************************************************************************************************************
Flush w/ 30 ml water q8h
*************************************************************************************************************
GI: Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,
*************************************************************************************************************
PEG site clean and dry. Peg to gravity drainage
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
49 year old male with Mitral valve endocarditis, preop stroke s/p MVR
*************************************************************************************************************
and debridement of aortic valve [**1-27**], patient failed S & S evaluation,
*************************************************************************************************************
TPN started over the weekend while awaiting PEG. PEG placed
*************************************************************************************************************
yesterday, plan to start tube feeds today, current tube feed order not
*************************************************************************************************************
meeting patient
*************************************************************************************************************
s estimated need. Noted patient with post op fluid
*************************************************************************************************************
gain, recommend fluid restricted formula.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
Consider ordering day 1 TPN tonight while slowly advancing
*************************************************************************************************************
tube feed
*************************************************************************************************************
Tube feeding: Isosource 1.5cal goal 45ml/hr ( 1620kcal/73g
*************************************************************************************************************
protein)
*************************************************************************************************************
Start tube feed at 15ml/hr and adv slowly as tol
*************************************************************************************************************
Check chemistry 10 panel daily, replete prn
*************************************************************************************************************
Continue BS management
*************************************************************************************************************
[**Numeric Identifier 943**] if has question
*************************************************************************************************************
"
*************************************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************************************
patient sleeping
*************************************************************************************************************
Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
178 cm
*************************************************************************************************************
63 kg
*************************************************************************************************************
74.9 kg ([**2113-2-3**] 04:00 AM)
*************************************************************************************************************
19.9
*************************************************************************************************************
Pertinent medications: D5 @10 ml/hr, KCl (40 mEq repletion), RISS, IV
*************************************************************************************************************
abx, lansoprazole, famotidine, others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
73
*************************************************************************************************************
[**2113-2-4**] 12:00 PM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
135
*************************************************************************************************************
[**2113-2-4**] 12:00 AM
*************************************************************************************************************
BUN
*************************************************************************************************************
25 mg/dL
*************************************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
1.6 mg/dL
*************************************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
140 mEq/L
*************************************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.5 mEq/L
*************************************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
108 mEq/L
*************************************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
22 mEq/L
*************************************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
65 mm Hg
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
PO2 (venous)
*************************************************************************************************************
48 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
30 mm Hg
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
PCO2 (venous)
*************************************************************************************************************
33 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.46 units
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
pH (venous)
*************************************************************************************************************
7.43 units
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.5 units
*************************************************************************************************************
[**2113-2-1**] 07:16 AM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
22 mEq/L
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
CO2 (Calc) venous
*************************************************************************************************************
23 mEq/L
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
Albumin
*************************************************************************************************************
2.1 g/dL
*************************************************************************************************************
[**2113-2-1**] 02:44 PM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
7.3 mg/dL
*************************************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
3.1 mg/dL
*************************************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************************************
Ionized Calcium
*************************************************************************************************************
1.08 mmol/L
*************************************************************************************************************
[**2113-1-30**] 11:46 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
2.0 mg/dL
*************************************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************************************
ALT
*************************************************************************************************************
23 IU/L
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Alkaline Phosphate
*************************************************************************************************************
51 IU/L
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
AST
*************************************************************************************************************
24 IU/L
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Amylase
*************************************************************************************************************
40 IU/L
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Total Bilirubin
*************************************************************************************************************
0.3 mg/dL
*************************************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************************************
Triglyceride
*************************************************************************************************************
120 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
13.4 K/uL
*************************************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
9.8 g/dL
*************************************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
29.7 %
*************************************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************************************
Current diet order / nutrition support: NPO
*************************************************************************************************************
GI: soft, hypoactive bowel sounds
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
Specifics: Patient s/p video swallow [**2-3**] which recommended patient be
*************************************************************************************************************
NPO. Received consult for PPN recommendations. Per discussion with PA,
*************************************************************************************************************
plan is for PEG placement on Monday and to supplement nutrition with
*************************************************************************************************************
parenteral nutrition until PEG is able to be used. Patient with PICC,
*************************************************************************************************************
Day 1 TPN ordered to start tonight. NGT was attempted earlier in week
*************************************************************************************************************
and was unable to placed and team thinks patient would pull it out.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
1. Day 1 TPN tonight
*************************************************************************************************************
2. Pending glycemic control advance to goal TPN 1.6L (270 g
*************************************************************************************************************
dextrose/80 g amino acids/35 g lipids)= 1588 kcals
*************************************************************************************************************
3. Check TG hold lipids if greater than 400
*************************************************************************************************************
4. Once PEG placed start with Isosource HN @ 15 ml/hr advance to
*************************************************************************************************************
goal of 45 ml/hr = 1620 kcals/ 73 g protein
*************************************************************************************************************
5. Will follow page [**Numeric Identifier 1372**] with questions
*************************************************************************************************************
"
*************************************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************************************
Patient asleep, [**Name8 (MD) 77**] RN, patient refused all po food or supplements.
*************************************************************************************************************
Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
178 cm
*************************************************************************************************************
63 kg
*************************************************************************************************************
70.5 kg ([**2113-1-19**] 08:00 AM)
*************************************************************************************************************
up due to fluid
*************************************************************************************************************
19.9
*************************************************************************************************************
Ideal body weight
*************************************************************************************************************
% Ideal body weight
*************************************************************************************************************
Adjusted weight
*************************************************************************************************************
Usual body weight
*************************************************************************************************************
% Usual body weight
*************************************************************************************************************
75.3 kg
*************************************************************************************************************
119%
*************************************************************************************************************
63 kg
*************************************************************************************************************
100%
*************************************************************************************************************
Diagnosis: MITRAL VALVE ENDOCARDITIS
*************************************************************************************************************
PMHx: None - no medical care x 30 years
*************************************************************************************************************
Food allergies and intolerances: not available
*************************************************************************************************************
Pertinent medications: Furosemide , Milrinone, Multivitamins, Thiamine,
*************************************************************************************************************
FoLIC Acid, Nicotine Patch, Heparin, Docusate Sodium , Nafcillin,
*************************************************************************************************************
Potassium Chloride, others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
117 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
BUN
*************************************************************************************************************
25 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
1.5 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
137 mEq/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.3 mEq/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
103 mEq/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
22 mEq/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
PO2 (venous)
*************************************************************************************************************
145 mm Hg
*************************************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************************************
PCO2 (venous)
*************************************************************************************************************
34 mm Hg
*************************************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************************************
pH (venous)
*************************************************************************************************************
7.45 units
*************************************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.0 units
*************************************************************************************************************
[**2113-1-18**] 12:03 PM
*************************************************************************************************************
CO2 (Calc) venous
*************************************************************************************************************
24 mEq/L
*************************************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************************************
Albumin
*************************************************************************************************************
1.9 g/dL
*************************************************************************************************************
[**2113-1-18**] 07:15 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
7.1 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
4.8 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
1.9 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
ALT
*************************************************************************************************************
36 IU/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Alkaline Phosphate
*************************************************************************************************************
44 IU/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
AST
*************************************************************************************************************
54 IU/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Total Bilirubin
*************************************************************************************************************
0.4 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
13.0 K/uL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
11.8 g/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
35.2 %
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Current diet order / nutrition support: Regular; Supplement: Ensure
*************************************************************************************************************
Plus breakfast, lunch, dinner
*************************************************************************************************************
GI: Abdominal: Soft, Non-tender, Bowel sounds present
*************************************************************************************************************
Extremities: Right lower extremity edema: Absent, Left lower extremity
*************************************************************************************************************
edema
*************************************************************************************************************
Skin: Warm, Rash: upper and lower ext, occ petechiae
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
At risk for malnutrition
*************************************************************************************************************
Patient at risk due to: Low po intake, current illness, head CT showed multipl
*************************************************************************************************************
e small non-hemorrhagic
*************************************************************************************************************
infarcts suspicious for septic emboli,
*************************************************************************************************************
Estimated Nutritional Needs
*************************************************************************************************************
Calories: 1575-1764 (BEE x or / 25-28 cal/kg)
*************************************************************************************************************
Protein: 76-88 (1.2-1.4 g/kg)
*************************************************************************************************************
Fluid: per team
*************************************************************************************************************
Calculations based on: Admit weight
*************************************************************************************************************
Estimation of previous intake: Inadequate
*************************************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************************************
Specifics:
*************************************************************************************************************
49 year old male found to have staphylococcus aureus bacterial
*************************************************************************************************************
endocarditis with severe mitral regurgitation [**3-21**] mitral valve
*************************************************************************************************************
vegetations and flail leaflet. Patient transferred from [**Hospital **] [**Hospital1 5**] for CT surgery evaluation and further management.
*************************************************************************************************************
Patient s/p speech and swallow evaluation, okay to have regular diet,
*************************************************************************************************************
yet patient refused to take pos. spoke to team this morning, team
*************************************************************************************************************
considering NGT placement.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
Po as tolerance
*************************************************************************************************************
Tube feeding recommendations: Nutren Pulmonary goal 45ml/hr
*************************************************************************************************************
(1620kcal/73.4g protein)
*************************************************************************************************************
Monitor tube feed tolerance
*************************************************************************************************************
Check chemistry 10 panel daily, replete as you are doing
*************************************************************************************************************
Consider adding phos binder if serum phos remains elevated
*************************************************************************************************************
Start regular insulin sliding scale if serum glucose greater
*************************************************************************************************************
than 150 mg/dL
*************************************************************************************************************
Other: [**Numeric Identifier 943**] if has question
*************************************************************************************************************
"
*************************************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************************************
Patient asleep, [**Name8 (MD) 77**] RN, patient refused all po food or supplements.
*************************************************************************************************************
Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
178 cm
*************************************************************************************************************
63 kg
*************************************************************************************************************
70.5 kg ([**2113-1-19**] 08:00 AM)
*************************************************************************************************************
up due to fluid
*************************************************************************************************************
19.9
*************************************************************************************************************
Ideal body weight
*************************************************************************************************************
% Ideal body weight
*************************************************************************************************************
Adjusted weight
*************************************************************************************************************
Usual body weight
*************************************************************************************************************
% Usual body weight
*************************************************************************************************************
75.3 kg
*************************************************************************************************************
119%
*************************************************************************************************************
63 kg
*************************************************************************************************************
100%
*************************************************************************************************************
Diagnosis: MITRAL VALVE ENDOCARDITIS
*************************************************************************************************************
PMHx: None - no medical care x 30 years
*************************************************************************************************************
Food allergies and intolerances: not available
*************************************************************************************************************
Pertinent medications: Furosemide , Milrinone, Multivitamins, Thiamine,
*************************************************************************************************************
FoLIC Acid, Nicotine Patch, Heparin, Docusate Sodium , Nafcillin,
*************************************************************************************************************
Potassium Chloride, others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
117 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
BUN
*************************************************************************************************************
25 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
1.5 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
137 mEq/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.3 mEq/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
103 mEq/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
22 mEq/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
PO2 (venous)
*************************************************************************************************************
145 mm Hg
*************************************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************************************
PCO2 (venous)
*************************************************************************************************************
34 mm Hg
*************************************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************************************
pH (venous)
*************************************************************************************************************
7.45 units
*************************************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.0 units
*************************************************************************************************************
[**2113-1-18**] 12:03 PM
*************************************************************************************************************
CO2 (Calc) venous
*************************************************************************************************************
24 mEq/L
*************************************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************************************
Albumin
*************************************************************************************************************
1.9 g/dL
*************************************************************************************************************
[**2113-1-18**] 07:15 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
7.1 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
4.8 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
1.9 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
ALT
*************************************************************************************************************
36 IU/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Alkaline Phosphate
*************************************************************************************************************
44 IU/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
AST
*************************************************************************************************************
54 IU/L
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Total Bilirubin
*************************************************************************************************************
0.4 mg/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
13.0 K/uL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
11.8 g/dL
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
35.2 %
*************************************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************************************
Current diet order / nutrition support: Regular; Supplement: Ensure
*************************************************************************************************************
Plus breakfast, lunch, dinner
*************************************************************************************************************
GI: Abdominal: Soft, Non-tender, Bowel sounds present
*************************************************************************************************************
Extremities: Right lower extremity edema: Absent, Left lower extremity
*************************************************************************************************************
edema
*************************************************************************************************************
Skin: Warm, Rash: upper and lower ext, occ petechiae
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
At risk for malnutrition
*************************************************************************************************************
Patient at risk due to: Low po intake, current illness, head CT showed multipl
*************************************************************************************************************
e small non-hemorrhagic
*************************************************************************************************************
infarcts suspicious for septic emboli,
*************************************************************************************************************
Estimated Nutritional Needs
*************************************************************************************************************
Calories: 1575-1764 (BEE x or / 25-28 cal/kg)
*************************************************************************************************************
Protein: 76-88 (1.2-1.4 g/kg)
*************************************************************************************************************
Fluid: per team
*************************************************************************************************************
Calculations based on: Admit weight
*************************************************************************************************************
Estimation of previous intake: Inadequate
*************************************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************************************
Specifics:
*************************************************************************************************************
49 year old male found to have staphylococcus aureus bacterial
*************************************************************************************************************
endocarditis with severe mitral regurgitation [**3-21**] mitral valve
*************************************************************************************************************
vegetations and flail leaflet. Patient transferred from [**Hospital **] [**Hospital1 5**] for CT surgery evaluation and further management.
*************************************************************************************************************
Patient s/p speech and swallow evaluation, okay to have regular diet,
*************************************************************************************************************
yet patient refused to take pos. spoke to team this morning, team
*************************************************************************************************************
considering NGT placement.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
Po as tolerance
*************************************************************************************************************
Tube feeding recommendations: Nutren Pulmonary goal 45ml/hr
*************************************************************************************************************
(1620kcal/73.4g protein)
*************************************************************************************************************
Monitor tube feed tolerance
*************************************************************************************************************
Check chemistry 10 panel daily, replete as you are doing
*************************************************************************************************************
Consider adding phos binder if serum phos remains elevated
*************************************************************************************************************
Start regular insulin sliding scale if serum glucose greater
*************************************************************************************************************
than 150 mg/dL
*************************************************************************************************************
Other: [**Numeric Identifier 943**] if has question
*************************************************************************************************************
------ Protected Section ------
*************************************************************************************************************
Cardiology Teaching Physician Note
*************************************************************************************************************
On this day I saw, examined and was physically present with the
*************************************************************************************************************
resident / fellow for the key portions of the services provided. I
*************************************************************************************************************
agree with the above note and plans.
*************************************************************************************************************
I would add the following remarks:
*************************************************************************************************************
Medical Decision Making
*************************************************************************************************************
Patient slowly improving the am after aggressive diuresis and
*************************************************************************************************************
initiation of Milrinone. He is less dyspneic and saturations are in the
*************************************************************************************************************
95-96% range. Renal service feels ARF is multifactorial and sediment is
*************************************************************************************************************
c/w ATM. Createnine is stable today at 1.5. He is speaking clearly but
*************************************************************************************************************
somnolent and wife, [**Name (NI) 1880**], feels this is from not sleeping last night.
*************************************************************************************************************
WBC down to 13K from 14K yesterday. ID recommends continuing Nafcillin
*************************************************************************************************************
with bllod cultures with fever spikes. Source of fevers are unclear now
*************************************************************************************************************
and we may need to image his abdomen as he complains of intermittent
*************************************************************************************************************
abdominal pain. C-[**Doctor First Name 91**] continues to follow closely and would like to
*************************************************************************************************************
delay surgery for as long as possible.
*************************************************************************************************************
------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) **], MD
*************************************************************************************************************
on:[**2113-1-20**] 05:48 PM ------
*************************************************************************************************************
"
*************************************************************************************************************
40461,Nutrition,"Subjective: Did not speak with patient.
*************************************************************************************************************
Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
178 cm
*************************************************************************************************************
63 kg
*************************************************************************************************************
72 kg ([**2113-1-22**] 10:00 AM)
*************************************************************************************************************
19.9
*************************************************************************************************************
Pertinent medications: Milrinone, protonix, abx, others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
98 mg/dL
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
BUN
*************************************************************************************************************
27 mg/dL
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
1.0 mg/dL
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
137 mEq/L
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
4.3 mEq/L
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
107 mEq/L
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
19 mEq/L
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
61 mm Hg
*************************************************************************************************************
[**2113-1-22**] 12:22 AM
*************************************************************************************************************
PO2 (venous)
*************************************************************************************************************
48 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
31 mm Hg
*************************************************************************************************************
[**2113-1-22**] 12:22 AM
*************************************************************************************************************
PCO2 (venous)
*************************************************************************************************************
33 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.37 units
*************************************************************************************************************
[**2113-1-22**] 12:22 AM
*************************************************************************************************************
pH (venous)
*************************************************************************************************************
7.43 units
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.0 units
*************************************************************************************************************
[**2113-1-20**] 06:24 PM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
19 mEq/L
*************************************************************************************************************
[**2113-1-22**] 12:22 AM
*************************************************************************************************************
CO2 (Calc) venous
*************************************************************************************************************
23 mEq/L
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
Albumin
*************************************************************************************************************
2.1 g/dL
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
7.6 mg/dL
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
3.8 mg/dL
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
2.0 mg/dL
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
ALT
*************************************************************************************************************
27 IU/L
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Alkaline Phosphate
*************************************************************************************************************
50 IU/L
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
AST
*************************************************************************************************************
27 IU/L
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Total Bilirubin
*************************************************************************************************************
0.3 mg/dL
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
20.7 K/uL
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
12.9 g/dL
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
39.5 %
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Current diet order / nutrition support: Diet: Regular/ heart healthy,
*************************************************************************************************************
with ensure plus TID
*************************************************************************************************************
GI: abd soft, bowel sounds present
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
49 year old male found to have staphylococcus aureus bacterial
*************************************************************************************************************
endocarditis with severe mitral regurgitation [**3-21**] mitral valve
*************************************************************************************************************
vegetations and flail leaflet. Patient transferred from [**Hospital **] to [**Hospital1 5**] for CT surgery evaluation and further management.
*************************************************************************************************************
Patient s/p speech and swallow evaluation, okay to have regular diet,
*************************************************************************************************************
yet patient is only taking small amounts of po
*************************************************************************************************************
s due to mental status.
*************************************************************************************************************
Team is planning to place an NGT for start of tube feeds. Tube
*************************************************************************************************************
feeding are recommendations below; these can be adjusted based on
*************************************************************************************************************
amount of po
*************************************************************************************************************
s patient is taking.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
To meet 100% of estimated needs, recommend Nutren Pulmonary
*************************************************************************************************************
@ 45mL/hr (1620kcals, 73g protein)
*************************************************************************************************************
Will monitor po intake and mental status and adjust tube
*************************************************************************************************************
feeds as needed.
*************************************************************************************************************
Following g- #[**Numeric Identifier 1312**]
*************************************************************************************************************
"
*************************************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************************************
intub
*************************************************************************************************************
Objective
*************************************************************************************************************
Pertinent medications: Multivitamins, FoLIC Acid , Pantoprazole,
*************************************************************************************************************
Potassium Chloride, Norepinephrine drip, others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
106 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
BUN
*************************************************************************************************************
15 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
1.1 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
140 mEq/L
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.7 mEq/L
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
108 mEq/L
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
26 mEq/L
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
108 mm Hg
*************************************************************************************************************
[**2113-1-25**] 03:53 AM
*************************************************************************************************************
PO2 (venous)
*************************************************************************************************************
48 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
53 mm Hg
*************************************************************************************************************
[**2113-1-25**] 03:53 AM
*************************************************************************************************************
PCO2 (venous)
*************************************************************************************************************
33 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.32 units
*************************************************************************************************************
[**2113-1-25**] 03:53 AM
*************************************************************************************************************
pH (venous)
*************************************************************************************************************
7.43 units
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.0 units
*************************************************************************************************************
[**2113-1-25**] 02:26 PM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
29 mEq/L
*************************************************************************************************************
[**2113-1-25**] 03:53 AM
*************************************************************************************************************
CO2 (Calc) venous
*************************************************************************************************************
23 mEq/L
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
Albumin
*************************************************************************************************************
2.1 g/dL
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
7.4 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
3.5 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
1.6 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
ALT
*************************************************************************************************************
27 IU/L
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Alkaline Phosphate
*************************************************************************************************************
50 IU/L
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
AST
*************************************************************************************************************
27 IU/L
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Amylase
*************************************************************************************************************
25 IU/L
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Total Bilirubin
*************************************************************************************************************
0.3 mg/dL
*************************************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************************************
Triglyceride
*************************************************************************************************************
120 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
11.4 K/uL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
9.6 g/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
30.3 %
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
Current diet order / nutrition support: Nutren Pulmonary Full strength;
*************************************************************************************************************
Additives: Banana flakes, 3 packets per day
*************************************************************************************************************
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 45 ml/hr
*************************************************************************************************************
Residual Check: q4h Hold feeding for residual >= : 200 ml
*************************************************************************************************************
Flush w/ 100 ml water q8h ( not running since 8 am this morning)
*************************************************************************************************************
NPO for Procedure Start: After 12:01AM Procedure: CSURG on date
*************************************************************************************************************
[**2113-1-26**]
*************************************************************************************************************
Do NOT resume diet after procedure.
*************************************************************************************************************
GI: Abd: soft, ND, NT, NBS
*************************************************************************************************************
Ext: 2+ pulses, 2+ edema in lower extremtiies R>L
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
49 year old male found to have staphlyococcus aureus bacterial
*************************************************************************************************************
endocarditis with severe mitral regurgitation [**3-21**] mitral valve
*************************************************************************************************************
vegetations and flail leaflet, patient pending OR tomorrow for AVR and
*************************************************************************************************************
MVR with debridement of the epidural abscess. Patient received minimal
*************************************************************************************************************
nutrition since admission (had <24hours tube feed from 12/7-8), at very
*************************************************************************************************************
high risk for malnutrition, recommend closely monitor post cardiac
*************************************************************************************************************
surgery, may need to restart tube feed as patient was refusing all po
*************************************************************************************************************
food this admission.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
Multivitamin / Mineral supplement: discontinue outside order
*************************************************************************************************************
if tube feed restarts
*************************************************************************************************************
Tube feeding recommendations: restart tube feed as ordered
*************************************************************************************************************
Check chemistry 10 panel daily, replete as you are doing
*************************************************************************************************************
Start regular insulin sliding scale if serum glucose greater
*************************************************************************************************************
than 150 mg/dL
*************************************************************************************************************
Other: [**Numeric Identifier 943**] if has question
*************************************************************************************************************
"
*************************************************************************************************************
40461,Nutrition,"Ht: 70
*************************************************************************************************************
Wt: 57.8 kg
*************************************************************************************************************
IBW: 75.3 kg/ 77%
*************************************************************************************************************
BMI: 18.2
*************************************************************************************************************
Pmh: Diabetes,Dyslipidemia,Hypertension, [**1-25**] multiple embolic events
*************************************************************************************************************
worst is large left posterior cerebral artery infarct(neurologic
*************************************************************************************************************
deficits including left sided facial droop, right sided neglect, right
*************************************************************************************************************
sided hemiparesis, expressive aphasia),
*************************************************************************************************************
MVR(29mm St. [**Male First Name (un) 1104**] Mechanical Valve) with Debridement of Aortic Valve.
*************************************************************************************************************
Teeth extraction [**2113-1-23**].
*************************************************************************************************************
Diet Order: regular
*************************************************************************************************************
49 year old male was in rehab s/p M. Patient admitted to outside
*************************************************************************************************************
hospital CT showed depressed fx of right frontal sinus. Patient
*************************************************************************************************************
transferred
*************************************************************************************************************
Potential for nutrition risk. Patient being monitored. Current
*************************************************************************************************************
intervention if any, listed below:
*************************************************************************************************************
Comments:
*************************************************************************************************************
"
*************************************************************************************************************
40461,Nutrition,"Ht: 70
*************************************************************************************************************
Wt: 57.8 kg
*************************************************************************************************************
IBW: 75.3 kg/ 77%
*************************************************************************************************************
BMI: 18.2
*************************************************************************************************************
Pmh: Diabetes,Dyslipidemia,Hypertension, [**1-25**] multiple embolic events
*************************************************************************************************************
worst is large left posterior cerebral artery infarct(neurologic
*************************************************************************************************************
deficits including left sided facial droop, right sided neglect, right
*************************************************************************************************************
sided hemiparesis, expressive aphasia),
*************************************************************************************************************
MVR(29mm St. [**Male First Name (un) 1104**] Mechanical Valve) with Debridement of Aortic Valve.
*************************************************************************************************************
Teeth extraction [**2113-1-23**].
*************************************************************************************************************
Diet Order: regular
*************************************************************************************************************
49 year old male on coumadin for a prosthetic mitral valve after
*************************************************************************************************************
having Staphylococcal endocarditis of MV and AV, c/b multiple embolic
*************************************************************************************************************
strokes admitted from rehab s/p fall. Patient tolerating diet no nausea
*************************************************************************************************************
or vomiting. Patient reports much better po intake since admit to
*************************************************************************************************************
[**Hospital1 5**]. Patient unsure of wt loss PTA and unsure of usual body wt. Will
*************************************************************************************************************
add supplements to increase caloric intake.
*************************************************************************************************************
Recommendations:
*************************************************************************************************************
1. Encourage pos and supplements
*************************************************************************************************************
2. Will add ensure TID
*************************************************************************************************************
3. Will follow page [**Numeric Identifier 1372**] with questions
*************************************************************************************************************
"
*************************************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************************************
oriented x 1
*************************************************************************************************************
Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
178 cm
*************************************************************************************************************
63 kg
*************************************************************************************************************
72 kg ([**2113-2-1**] 04:00 AM)
*************************************************************************************************************
19.9
*************************************************************************************************************
Pertinent medications: Ranitidine, ABX, Folic Acid, Thiamine,
*************************************************************************************************************
Multi-vitamin, lasix, Colace (Held), KCl (20mEq repletion x3)
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
108 mg/dL
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
124
*************************************************************************************************************
[**2113-2-1**] 12:00 AM
*************************************************************************************************************
BUN
*************************************************************************************************************
28 mg/dL
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
2.0 mg/dL
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
139 mEq/L
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.7 mEq/L
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
105 mEq/L
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
23 mEq/L
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
65 mm Hg
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
PO2 (venous)
*************************************************************************************************************
48 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
30 mm Hg
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
PCO2 (venous)
*************************************************************************************************************
33 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.46 units
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
pH (venous)
*************************************************************************************************************
7.43 units
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.5 units
*************************************************************************************************************
[**2113-2-1**] 07:16 AM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
22 mEq/L
*************************************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************************************
CO2 (Calc) venous
*************************************************************************************************************
23 mEq/L
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
Albumin
*************************************************************************************************************
2.2 g/dL
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
7.6 mg/dL
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
4.6 mg/dL
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
Ionized Calcium
*************************************************************************************************************
1.08 mmol/L
*************************************************************************************************************
[**2113-1-30**] 11:46 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
2.2 mg/dL
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
ALT
*************************************************************************************************************
20 IU/L
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Alkaline Phosphate
*************************************************************************************************************
57 IU/L
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
AST
*************************************************************************************************************
26 IU/L
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Amylase
*************************************************************************************************************
17 IU/L
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Total Bilirubin
*************************************************************************************************************
0.4 mg/dL
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Triglyceride
*************************************************************************************************************
120 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
18.2 K/uL
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
10.4 g/dL
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
31.5 %
*************************************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************************************
Current diet order / nutrition support: Diet: Ground solids, thin
*************************************************************************************************************
liquids; Ensure Pudding and Carnation Instant Breakfast with meals;
*************************************************************************************************************
calorie counts [**2-1**], [**2-2**], [**2-3**]
*************************************************************************************************************
GI: soft, (+) bowel sounds; green liquid stool
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************************************
Specifics:
*************************************************************************************************************
Patient s/p MVR / AVR [**1-27**]. Extubated [**1-30**]. Seen by SLP [**1-31**] who
*************************************************************************************************************
recommended above altered consistency diet with 1:1 supervision. [**Name8 (MD) **]
*************************************************************************************************************
RN, patient took Ensure pudding and some Carnation Instant Breakfast
*************************************************************************************************************
shake this AM with a lot of encouragement. Patient takes very small
*************************************************************************************************************
bites and is a picky eater. RN reports wife to bring in a list of
*************************************************************************************************************
foods that patient likes. Calorie counts starting today. Concerned
*************************************************************************************************************
with nutrition status given poor po
*************************************************************************************************************
s during admit (refusing po
*************************************************************************************************************
s at
*************************************************************************************************************
times), only received tube feed briefly on/off and recent surgery.
*************************************************************************************************************
Would strongly recommend supplemental tube feed to optimize nutrition
*************************************************************************************************************
for post-op recovery.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
Current diet / nutrition support is appropriate:
*************************************************************************************************************
Encourage/assist with po
*************************************************************************************************************
o Encourage wife to bring in food preference list or food
*************************************************************************************************************
o Calorie counts
*************************************************************************************************************
please record on kitchen receipt percent
*************************************************************************************************************
eaten
*************************************************************************************************************
Oral supplements: Continue as ordered
*************************************************************************************************************
Multivitamin / Mineral supplement: continue current
*************************************************************************************************************
Tube feeding recommendations:
*************************************************************************************************************
o Consider placing NGT and beginning tube feeds to supplement
*************************************************************************************************************
poor po
*************************************************************************************************************
o Tube feed goal would be: Nutren Pulmonary @ 45ml/hr = 1620
*************************************************************************************************************
calories and 73g protein
*************************************************************************************************************
Check chemistry 10 panel daily
*************************************************************************************************************
Will follow, page if questions *[**Numeric Identifier 606**]
*************************************************************************************************************
"
*************************************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************************************
just extubated
*************************************************************************************************************
Objective
*************************************************************************************************************
Height
*************************************************************************************************************
Admit weight
*************************************************************************************************************
Daily weight
*************************************************************************************************************
Weight change
*************************************************************************************************************
BMI
*************************************************************************************************************
178 cm
*************************************************************************************************************
63 kg
*************************************************************************************************************
76.2 kg ([**2113-1-30**] 04:00 AM)
*************************************************************************************************************
19.9
*************************************************************************************************************
Pertinent medications: Multivitamins, others noted
*************************************************************************************************************
Labs:
*************************************************************************************************************
Value
*************************************************************************************************************
Date
*************************************************************************************************************
Glucose
*************************************************************************************************************
106 mg/dL
*************************************************************************************************************
[**2113-1-30**] 07:59 AM
*************************************************************************************************************
Glucose Finger Stick
*************************************************************************************************************
93
*************************************************************************************************************
[**2113-1-29**] 06:00 PM
*************************************************************************************************************
BUN
*************************************************************************************************************
20 mg/dL
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Creatinine
*************************************************************************************************************
1.6 mg/dL
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Sodium
*************************************************************************************************************
137 mEq/L
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Potassium
*************************************************************************************************************
3.5 mEq/L
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Chloride
*************************************************************************************************************
104 mEq/L
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
TCO2
*************************************************************************************************************
22 mEq/L
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
PO2 (arterial)
*************************************************************************************************************
85.[**Numeric Identifier 299**] mm Hg
*************************************************************************************************************
[**2113-1-30**] 09:19 AM
*************************************************************************************************************
PO2 (venous)
*************************************************************************************************************
48 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
PCO2 (arterial)
*************************************************************************************************************
33 mm Hg
*************************************************************************************************************
[**2113-1-30**] 09:19 AM
*************************************************************************************************************
PCO2 (venous)
*************************************************************************************************************
33 mm Hg
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (arterial)
*************************************************************************************************************
7.41 units
*************************************************************************************************************
[**2113-1-30**] 09:19 AM
*************************************************************************************************************
pH (venous)
*************************************************************************************************************
7.43 units
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
pH (urine)
*************************************************************************************************************
5.0 units
*************************************************************************************************************
[**2113-1-25**] 02:26 PM
*************************************************************************************************************
CO2 (Calc) arterial
*************************************************************************************************************
22 mEq/L
*************************************************************************************************************
[**2113-1-30**] 09:19 AM
*************************************************************************************************************
CO2 (Calc) venous
*************************************************************************************************************
23 mEq/L
*************************************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************************************
Albumin
*************************************************************************************************************
2.2 g/dL
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Calcium non-ionized
*************************************************************************************************************
8.4 mg/dL
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Phosphorus
*************************************************************************************************************
5.2 mg/dL
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Ionized Calcium
*************************************************************************************************************
1.09 mmol/L
*************************************************************************************************************
[**2113-1-30**] 07:59 AM
*************************************************************************************************************
Magnesium
*************************************************************************************************************
2.1 mg/dL
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
ALT
*************************************************************************************************************
20 IU/L
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Alkaline Phosphate
*************************************************************************************************************
57 IU/L
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
AST
*************************************************************************************************************
26 IU/L
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Amylase
*************************************************************************************************************
17 IU/L
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Total Bilirubin
*************************************************************************************************************
0.4 mg/dL
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Triglyceride
*************************************************************************************************************
120 mg/dL
*************************************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************************************
WBC
*************************************************************************************************************
11.5 K/uL
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Hgb
*************************************************************************************************************
10.3 g/dL
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Hematocrit
*************************************************************************************************************
30.1 %
*************************************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************************************
Current diet order / nutrition support: Nutren Pulmonary Full strength;
*************************************************************************************************************
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr
*************************************************************************************************************
Residual Check: q4h Hold feeding for residual >= : 200 ml
*************************************************************************************************************
Flush w/ 30 ml water q4h ( not running)
*************************************************************************************************************
GI: soft, flesiseal in place
*************************************************************************************************************
SKIN: stage 2 wounds
*************************************************************************************************************
Assessment of Nutritional Status
*************************************************************************************************************
49 year old male admitted on [**1-15**] with endocarditis s/p MVR and aortic
*************************************************************************************************************
valve debridement on [**1-27**], patient extubated this morning. Patient
*************************************************************************************************************
well known to me from CCU, patient with minimal nutrition since
*************************************************************************************************************
hospital admission (previously refused po food and nutrition
*************************************************************************************************************
supplements in the ccu, received 1 day of tube feed prior to OR.
*************************************************************************************************************
Patient at very high risk for malnutrition, highly recommend replace
*************************************************************************************************************
feeding tube, restart tube feed as temporary nutrition support for post
*************************************************************************************************************
op recovery.
*************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************************************
Adv diet if remains medically stable
*************************************************************************************************************
Continue tube feed as supplemental nutrition support: goal
*************************************************************************************************************
Nutren Pulmonary goal 45ml/hr to provide 1620kcal/73.4g protein
*************************************************************************************************************
Phos binder if serum phos remains elevated
*************************************************************************************************************
Check chemistry 10 panel daily, replete prn
*************************************************************************************************************
BS management
*************************************************************************************************************
Other: [**Numeric Identifier 943**]
*************************************************************************************************************
"
*************************************************************************************************************
In [24]:
# Token
token_without_punct = []
for i in range(len(doc)):
token_without_punct.append([token.orth_ for token in doc[i] if not token.is_punct | token.is_space])
print(token_without_punct[-1])
print('*******************************************************************************************')
['SUBJECT_ID', 'CATEGORY', 'TEXT'] ******************************************************************************************* ['17610,Nutrition,"Patient', 'transferred', 'to', 'MICU', 'for', 'concern', 'for', 'aspiration', 'Diet', 'changed'] ******************************************************************************************* ['to', 'NPO', 'NGT', 'in', 'for', 'medication', 'Noted', 'plan', 'to', 'transition', 'to', 'comfort'] ******************************************************************************************* ['focused', 'care'] ******************************************************************************************* ['Will', 'sign', 'off', 'at', 'this', 'time', 'Please', 'consult', 'if', 'needed', 'Pager', 'Numeric', 'Identifier', '5307'] ******************************************************************************************* [] ******************************************************************************************* ['40493,Nutrition,"Objective'] ******************************************************************************************* ['Pertinent', 'medications', 'RISS', 'SS', 'lytes', 'thiamin', 'folate', 'lasix', 'bowel'] ******************************************************************************************* ['regimen', 'MOM', 'reglan', 'others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['93', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '9', '01:50', 'AM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['120'] ******************************************************************************************* ['2172', '11', '9', '08:57', 'AM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['15', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '9', '01:50', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['0.6', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '9', '01:50', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['137', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '9', '01:50', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.9', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '9', '01:50', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['106', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '9', '01:50', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['24', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '9', '01:50', 'AM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['66', 'mm', 'Hg'] ******************************************************************************************* ['2172', '11', '9', '08:57', 'AM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['41', 'mm', 'Hg'] ******************************************************************************************* ['2172', '11', '9', '08:57', 'AM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.42', 'units'] ******************************************************************************************* ['2172', '11', '9', '08:57', 'AM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.0', 'units'] ******************************************************************************************* ['2172', '11', '1', '06:06', 'PM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['28', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '9', '08:57', 'AM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['2.6', 'g', 'dL'] ******************************************************************************************* ['2172', '11', '3', '02:24', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['8.7', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '9', '01:50', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['4.5', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '9', '01:50', 'AM'] ******************************************************************************************* ['Ionized', 'Calcium'] ******************************************************************************************* ['1.11', 'mmol', 'L'] ******************************************************************************************* ['2172', '11', '5', '01:34', 'PM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['2.2', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '9', '01:50', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Fibersource', 'HN@60mL', 'hr', '1728'] ******************************************************************************************* ['kcals/73', 'gr', 'aa', 'not', 'infusing'] ******************************************************************************************* ['GI', 'Abd', 'soft/+bs'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['Specifics'] ******************************************************************************************* ['Pt', 'extubated', 'earlier', 'today', 'Pt', 'was', 'previously', 'tolerating', 'TF'] ******************************************************************************************* ['s', 'goal'] ******************************************************************************************* ['meeting', '100', 'estimated', 'nutrition', 'needs', 'Anticipate', 'diet', 'advancement', 'as'] ******************************************************************************************* ['able'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['Advance', 'diet', 'per', 'team', 'c/', 'swallow', 'eval', 'if', 'pt', 'shows', 's', 's', 'of', 'aspiration', 'and'] ******************************************************************************************* ['advance', 'diet', 'per', 'SLP-', 'vs', 'place', 'NGT', 'and', 'resume', 'TF', "'s", 'if', 'unable', 'to', 'take'] ******************************************************************************************* ['po'] ******************************************************************************************* ['Will', 'follow', 'plan', '-please', 'page', 'c/', "'s", 'Numeric', 'Identifier', '1684'] ******************************************************************************************* [] ******************************************************************************************* ['40493,Nutrition,"Subjective'] ******************************************************************************************* ['intubated'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['168', 'cm'] ******************************************************************************************* ['65', 'kg'] ******************************************************************************************* ['23.1'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Adjusted', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['64.4', 'kg'] ******************************************************************************************* ['101'] ******************************************************************************************* ['Diagnosis', 'S', 'P', 'Fall'] ******************************************************************************************* ['PMH', 'etoh', 'smoker', 'cirrhosis'] ******************************************************************************************* ['Food', 'allergies', 'and', 'intolerances', 'NKFA'] ******************************************************************************************* ['Pertinent', 'medications', 'fentanyl', 'LR', '10', 'ml', 'hr', 'lasix', 'versed', 'RISS', 'IV'] ******************************************************************************************* ['abx', 'others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['155', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['151'] ******************************************************************************************* ['2172', '11', '2', '08:00', 'AM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['17', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['0.8', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['146', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.6', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['111', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['29', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['113', 'mm', 'Hg'] ******************************************************************************************* ['2172', '11', '2', '11:55', 'AM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['41', 'mm', 'Hg'] ******************************************************************************************* ['2172', '11', '2', '11:55', 'AM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.46', 'units'] ******************************************************************************************* ['2172', '11', '2', '11:55', 'AM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.0', 'units'] ******************************************************************************************* ['2172', '11', '1', '06:06', 'PM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['30', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '2', '11:55', 'AM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['3.0', 'g', 'dL'] ******************************************************************************************* ['2172', '10', '31', '02:55', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['8.1', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['2.5', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Ionized', 'Calcium'] ******************************************************************************************* ['1.16', 'mmol', 'L'] ******************************************************************************************* ['2172', '11', '2', '11:55', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['1.7', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['ALT'] ******************************************************************************************* ['14', 'IU', 'L'] ******************************************************************************************* ['2172', '10', '31', '02:55', 'AM'] ******************************************************************************************* ['Alkaline', 'Phosphate'] ******************************************************************************************* ['73', 'IU', 'L'] ******************************************************************************************* ['2172', '10', '31', '02:55', 'AM'] ******************************************************************************************* ['AST'] ******************************************************************************************* ['43', 'IU', 'L'] ******************************************************************************************* ['2172', '10', '31', '02:55', 'AM'] ******************************************************************************************* ['Total', 'Bilirubin'] ******************************************************************************************* ['3.4', 'mg', 'dL'] ******************************************************************************************* ['2172', '10', '31', '02:55', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['23.2', 'K', 'uL'] ******************************************************************************************* ['2172', '11', '2', '01:06', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['9.1', 'g', 'dL'] ******************************************************************************************* ['2172', '11', '2', '01:06', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['27.2'] ******************************************************************************************* ['2172', '11', '2', '01:06', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'NPO', 'replete', 'with', 'fiber', '60'] ******************************************************************************************* ['ml', 'hr'] ******************************************************************************************* ['GI', 'OGT'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['At', 'risk', 'for', 'malnutrition'] ******************************************************************************************* ['Pt', 'at', 'risk', 'due', 'to', 'NPO', 'hypocaloric', 'diet'] ******************************************************************************************* ['Estimated', 'Nutritional', 'Needs'] ******************************************************************************************* ['Calories', '1625-[**2114', '25', '30', 'cal', 'kg'] ******************************************************************************************* ['Protein', '78', '91', '1.2', '1.4', 'g', 'kg'] ******************************************************************************************* ['Fluid', 'per', 'team'] ******************************************************************************************* ['Estimation', 'of', 'previous', 'intake', 'Likely', 'Adequate'] ******************************************************************************************* ['Estimation', 'of', 'current', 'intake', 'Inadequate'] ******************************************************************************************* ['Specifics', '57', 'year', 'old', 'male', 'transferred', 'from', 'OSH', 'intubated', 'there', 'Pt'] ******************************************************************************************* ['S', 'P', 'fall', 'CT', 'shows', 'Stage', 'IV', 'splenic', 'laceration', 'Tolerating', 'TF', 'with'] ******************************************************************************************* ['minimal', 'residuals', 'Name8', 'MD', 'RN', 'Current', 'TF', 'provides', '1440', 'kcals/89', 'g', 'Pro'] ******************************************************************************************* ['Recommend', 'changing', 'TF', 'to', 'better', 'meet', 'nutritional', 'needs'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['1', 'Check', 'chemistry', '10', 'panel', 'daily'] ******************************************************************************************* ['2', 'Change', 'TF', 'to', 'goal', 'of', 'Fibersource', 'HN', '65ml', 'hr', '1872', 'kcals/83', 'g'] ******************************************************************************************* ['Pro'] ******************************************************************************************* ['3', 'Pls', 'page', 'with', 'questions', 'Numeric', 'Identifier', '2584'] ******************************************************************************************* [] ******************************************************************************************* ['40493,Nutrition,"Subjective'] ******************************************************************************************* ['intubated'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['168', 'cm'] ******************************************************************************************* ['65', 'kg'] ******************************************************************************************* ['23.1'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Adjusted', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['64.4', 'kg'] ******************************************************************************************* ['101'] ******************************************************************************************* ['Diagnosis', 'S', 'P', 'Fall'] ******************************************************************************************* ['PMH', 'etoh', 'smoker', 'cirrhosis'] ******************************************************************************************* ['Food', 'allergies', 'and', 'intolerances', 'NKFA'] ******************************************************************************************* ['Pertinent', 'medications', 'fentanyl', 'LR', '10', 'ml', 'hr', 'lasix', 'versed', 'RISS', 'IV'] ******************************************************************************************* ['abx', 'others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['155', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['151'] ******************************************************************************************* ['2172', '11', '2', '08:00', 'AM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['17', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['0.8', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['146', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.6', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['111', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['29', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['113', 'mm', 'Hg'] ******************************************************************************************* ['2172', '11', '2', '11:55', 'AM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['41', 'mm', 'Hg'] ******************************************************************************************* ['2172', '11', '2', '11:55', 'AM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.46', 'units'] ******************************************************************************************* ['2172', '11', '2', '11:55', 'AM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.0', 'units'] ******************************************************************************************* ['2172', '11', '1', '06:06', 'PM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['30', 'mEq', 'L'] ******************************************************************************************* ['2172', '11', '2', '11:55', 'AM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['3.0', 'g', 'dL'] ******************************************************************************************* ['2172', '10', '31', '02:55', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['8.1', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['2.5', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['Ionized', 'Calcium'] ******************************************************************************************* ['1.16', 'mmol', 'L'] ******************************************************************************************* ['2172', '11', '2', '11:55', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['1.7', 'mg', 'dL'] ******************************************************************************************* ['2172', '11', '2', '12:18', 'PM'] ******************************************************************************************* ['ALT'] ******************************************************************************************* ['14', 'IU', 'L'] ******************************************************************************************* ['2172', '10', '31', '02:55', 'AM'] ******************************************************************************************* ['Alkaline', 'Phosphate'] ******************************************************************************************* ['73', 'IU', 'L'] ******************************************************************************************* ['2172', '10', '31', '02:55', 'AM'] ******************************************************************************************* ['AST'] ******************************************************************************************* ['43', 'IU', 'L'] ******************************************************************************************* ['2172', '10', '31', '02:55', 'AM'] ******************************************************************************************* ['Total', 'Bilirubin'] ******************************************************************************************* ['3.4', 'mg', 'dL'] ******************************************************************************************* ['2172', '10', '31', '02:55', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['23.2', 'K', 'uL'] ******************************************************************************************* ['2172', '11', '2', '01:06', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['9.1', 'g', 'dL'] ******************************************************************************************* ['2172', '11', '2', '01:06', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['27.2'] ******************************************************************************************* ['2172', '11', '2', '01:06', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'NPO', 'replete', 'with', 'fiber', '60'] ******************************************************************************************* ['ml', 'hr'] ******************************************************************************************* ['GI', 'OGT'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['At', 'risk', 'for', 'malnutrition'] ******************************************************************************************* ['Pt', 'at', 'risk', 'due', 'to', 'NPO', 'hypocaloric', 'diet'] ******************************************************************************************* ['Estimated', 'Nutritional', 'Needs'] ******************************************************************************************* ['Calories', '1625-[**2114', '25', '30', 'cal', 'kg'] ******************************************************************************************* ['Protein', '78', '91', '1.2', '1.4', 'g', 'kg'] ******************************************************************************************* ['Fluid', 'per', 'team'] ******************************************************************************************* ['Estimation', 'of', 'previous', 'intake', 'Likely', 'Adequate'] ******************************************************************************************* ['Estimation', 'of', 'current', 'intake', 'Inadequate'] ******************************************************************************************* ['Specifics', '57', 'year', 'old', 'male', 'transferred', 'from', 'OSH', 'intubated', 'there', 'Pt'] ******************************************************************************************* ['S', 'P', 'fall', 'CT', 'shows', 'Stage', 'IV', 'splenic', 'laceration', 'Tolerating', 'TF', 'with'] ******************************************************************************************* ['minimal', 'residuals', 'Name8', 'MD', 'RN', 'Current', 'TF', 'provides', '1440', 'kcals/89', 'g', 'Pro'] ******************************************************************************************* ['Recommend', 'changing', 'TF', 'to', 'better', 'meet', 'nutritional', 'needs'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['1', 'Check', 'chemistry', '10', 'panel', 'daily'] ******************************************************************************************* ['2', 'Change', 'TF', 'to', 'goal', 'of', 'Fibersource', 'HN', '65ml', 'hr', '1872', 'kcals/83', 'g'] ******************************************************************************************* ['Pro'] ******************************************************************************************* ['3', 'Pls', 'page', 'with', 'questions', 'Numeric', 'Identifier', '2584'] ******************************************************************************************* [] ******************************************************************************************* ['61565,Nutrition,"Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['178', 'cm'] ******************************************************************************************* ['88.2', 'kg'] ******************************************************************************************* ['27.8'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Adjusted', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['75.3', 'kg'] ******************************************************************************************* ['117'] ******************************************************************************************* ['Diagnosis', 'Head', 'Bleed'] ******************************************************************************************* ['PMH', 'DM'] ******************************************************************************************* ['Food', 'allergies', 'and', 'intolerances'] ******************************************************************************************* ['Pertinent', 'medications', 'Esmolol', 'famotidine', 'colace', 'lytes', 'ss', 'dilantin'] ******************************************************************************************* ['ssri', 'others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['143', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['155'] ******************************************************************************************* ['2100', '11', '1', '02:00', 'AM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['18', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['0.8', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['142', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['4.1', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['111', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['26', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['109', 'mm', 'Hg'] ******************************************************************************************* ['2100', '11', '1', '04:35', 'AM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['38', 'mm', 'Hg'] ******************************************************************************************* ['2100', '11', '1', '04:35', 'AM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.48', 'units'] ******************************************************************************************* ['2100', '11', '1', '04:35', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['29', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '1', '04:35', 'AM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['3.8', 'g', 'dL'] ******************************************************************************************* ['2100', '10', '30', '03:27', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['8.9', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['2.5', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Ionized', 'Calcium'] ******************************************************************************************* ['1.22', 'mmol', 'L'] ******************************************************************************************* ['2100', '10', '31', '02:41', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['2.3', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Phenytoin', 'Dilantin'] ******************************************************************************************* ['10.1', 'ug', 'mL'] ******************************************************************************************* ['2100', '10', '31', '02:34', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['12.1', 'K', 'uL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['11.9', 'g', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['33.9'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Replete', 'with', 'fiber', 'Full'] ******************************************************************************************* ['strength', 'Goal', 'rate', '65', 'ml', 'hr'] ******************************************************************************************* ['Residual', 'Check', 'q4h', 'Hold', 'feeding', 'for', 'residual', '>', '=', '200', 'ml'] ******************************************************************************************* ['GI'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['At', 'risk', 'for', 'malnutrition'] ******************************************************************************************* ['Pt', 'at', 'risk', 'due', 'to', 'NPO', 'hypocaloric', 'diet'] ******************************************************************************************* ['Estimated', 'Nutritional', 'Needs'] ******************************************************************************************* ['Calories', '2027**]-2200', 'BEE', 'x', 'or', '22', '25', 'cal', 'kg'] ******************************************************************************************* ['Protein', '114', '1.3', 'g', 'kg'] ******************************************************************************************* ['Fluid'] ******************************************************************************************* ['Estimation', 'of', 'previous', 'intake', 'Adequate'] ******************************************************************************************* ['Estimation', 'of', 'current', 'intake', 'Inadequate'] ******************************************************************************************* ['Specifics'] ******************************************************************************************* ['72', 'yo', 'male', 's', 'p', 'witnessed', 'fall', 'w/', 'head', 'trauma', 'right', 'parietal', 'occipital'] ******************************************************************************************* ['SAH', 'w/', 'left', 'intraparenchymal', 'bleed', 'contre', 'coup', 'injury', 'Pt', 'started', 'on'] ******************************************************************************************* ['TF', 'yesterday', 'currently', 'tol', 'goal', 'TF', 'without', 'issue', 'per', 'chart', 'pt', 'with', '+'] ******************************************************************************************* ['gag', 'will', 'plan', 'to', 'extubate', 'this', 'am', 'If', 'unable', 'to', 'extubate', 'will', 'need'] ******************************************************************************************* ['to', 'change', 'TF', 'to', 'better', 'meet', 'pt', "'s", 'needs'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['Tube', 'feeding', 'recommendations'] ******************************************************************************************* ['Check', 'chemistry', '10', 'panel', 'daily', 'and', 'replete'] ******************************************************************************************* ['Cont', 'Bg', 'management'] ******************************************************************************************* ['Pplease', 'page', 'Numeric', 'Identifier', '1550', 'if', 'has'] ******************************************************************************************* [] ******************************************************************************************* ['61565,Nutrition,"Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['178', 'cm', 'est'] ******************************************************************************************* ['88.2', 'kg'] ******************************************************************************************* ['27.8'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Adjusted', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['75.3', 'kg'] ******************************************************************************************* ['117'] ******************************************************************************************* ['Diagnosis', 'Head', 'Bleed'] ******************************************************************************************* ['PMH', 'DM', 'HTN'] ******************************************************************************************* ['Food', 'allergies', 'and', 'intolerances'] ******************************************************************************************* ['Pertinent', 'medications', 'Esmolol', 'famotidine', 'colace', 'lytes', 'ss', 'dilantin'] ******************************************************************************************* ['ssri', 'others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['143', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['155'] ******************************************************************************************* ['2100', '11', '1', '02:00', 'AM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['18', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['0.8', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['142', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['4.1', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['111', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['26', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['109', 'mm', 'Hg'] ******************************************************************************************* ['2100', '11', '1', '04:35', 'AM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['38', 'mm', 'Hg'] ******************************************************************************************* ['2100', '11', '1', '04:35', 'AM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.48', 'units'] ******************************************************************************************* ['2100', '11', '1', '04:35', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['29', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '1', '04:35', 'AM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['3.8', 'g', 'dL'] ******************************************************************************************* ['2100', '10', '30', '03:27', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['8.9', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['2.5', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Ionized', 'Calcium'] ******************************************************************************************* ['1.22', 'mmol', 'L'] ******************************************************************************************* ['2100', '10', '31', '02:41', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['2.3', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Phenytoin', 'Dilantin'] ******************************************************************************************* ['10.1', 'ug', 'mL'] ******************************************************************************************* ['2100', '10', '31', '02:34', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['12.1', 'K', 'uL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['11.9', 'g', 'dL'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['33.9'] ******************************************************************************************* ['2100', '11', '1', '02:37', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Replete', 'with', 'fiber', 'Full'] ******************************************************************************************* ['strength', 'Goal', 'rate', '65', 'ml', 'hr', '1560kcal/96.7', 'g', 'pro'] ******************************************************************************************* ['Residual', 'Check', 'q4h', 'Hold', 'feeding', 'for', 'residual', '>', '=', '200', 'ml'] ******************************************************************************************* ['GI', 'Soft', 'Non', 'distended', 'Non', 'tender'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['At', 'risk', 'for', 'malnutrition'] ******************************************************************************************* ['Pt', 'at', 'risk', 'due', 'to', 'NPO'] ******************************************************************************************* ['Estimated', 'Nutritional', 'Needs'] ******************************************************************************************* ['Calories', '1760', '2200', 'BEE', 'x', 'or', '20', '25', 'cal', 'kg'] ******************************************************************************************* ['Protein', '114', '1.3', 'g', 'kg'] ******************************************************************************************* ['Fluid', 'per', 'team'] ******************************************************************************************* ['Estimation', 'of', 'previous', 'intake', 'likely', 'adequate'] ******************************************************************************************* ['Estimation', 'of', 'current', 'intake', 'Inadequate'] ******************************************************************************************* ['Specifics'] ******************************************************************************************* ['72', 'yo', 'male', 's', 'p', 'witnessed', 'fall', 'w/', 'head', 'trauma', 'right', 'parietal', 'occipital'] ******************************************************************************************* ['SAH', 'w/', 'left', 'intraparenchymal', 'bleed', 'contre', 'coup', 'injury', 'Pt', 'started', 'on'] ******************************************************************************************* ['TF', 'yesterday', 'currently', 'tol', 'goal', 'TF', 'without', 'issue', 'per', 'chart', 'pt', 'with', '+'] ******************************************************************************************* ['gag', 'cough', 'Last', 'Name', 'LF', '1080', 'First', 'Name3', 'LF', 'plan', 'to', 'extubate', 'this', 'am', 'If', 'unable', 'to'] ******************************************************************************************* ['extubate', 'will', 'need', 'to', 'change', 'TF', 'to', 'better', 'meet', 'pt', "'s", 'needs'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['Tube', 'feeding', 'recommendations', 'increase', 'TF', 'to', 'Replete', 'with', 'Fiber', 'goal'] ******************************************************************************************* ['75ml', 'hr', '1800kcal/112', 'g', 'pro'] ******************************************************************************************* ['Check', 'chemistry', '10', 'panel', 'daily', 'and', 'replete', 'prn'] ******************************************************************************************* ['Cont', 'Bg', 'management'] ******************************************************************************************* ['Please', 'page', 'Numeric', 'Identifier', '1550', 'if', 'has'] ******************************************************************************************* [] ******************************************************************************************* ['61565,Nutrition,"Objective'] ******************************************************************************************* ['Pertinent', 'medications', 'pepcid', 'Heparin', 'docusate', 'Abx', 'RISS', 'others'] ******************************************************************************************* ['noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['128', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '5', '03:32', 'AM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['140'] ******************************************************************************************* ['2100', '11', '4', '08:00', 'PM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['18', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '5', '03:32', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['0.7', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '5', '03:32', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['140', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '5', '03:32', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.9', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '5', '03:32', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['103', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '5', '03:32', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['28', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '5', '03:32', 'AM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['94.[**Numeric', 'Identifier', '126', 'mm', 'Hg'] ******************************************************************************************* ['2100', '11', '5', '07:26', 'AM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['37', 'mm', 'Hg'] ******************************************************************************************* ['2100', '11', '5', '07:26', 'AM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.49', 'units'] ******************************************************************************************* ['2100', '11', '5', '07:26', 'AM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['7.0', 'units'] ******************************************************************************************* ['2100', '11', '5', '11:05', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['29', 'mEq', 'L'] ******************************************************************************************* ['2100', '11', '5', '07:26', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['8.7', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '4', '02:31', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['3.0', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '4', '02:31', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['2.3', 'mg', 'dL'] ******************************************************************************************* ['2100', '11', '4', '02:31', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['12.2', 'K', 'uL'] ******************************************************************************************* ['2100', '11', '5', '03:32', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['12.0', 'g', 'dL'] ******************************************************************************************* ['2100', '11', '5', '03:32', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['33.8'] ******************************************************************************************* ['2100', '11', '5', '03:32', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Replete', 'c/', 'Fiber', '@65mL', 'hr', '1560'] ******************************************************************************************* ['kcals/97', 'gr', 'aa'] ******************************************************************************************* ['GI', 'Abd', 'soft/+bs'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['Estimation', 'of', 'current', 'intake', 'Inadequate'] ******************************************************************************************* ['Specifics'] ******************************************************************************************* ['Pt', 's', 'p', 'trach', 'PEG', 'and', 'IVC', 'filter', 'yesterday', 'TF'] ******************************************************************************************* ['s', 'currently', 'infusing'] ******************************************************************************************* ['10mL', 'hr', 'Current', 'goal', 'Rx', 'will', 'meet', '88', 'estimated', 'kcal', 'and', '85', 'estimated'] ******************************************************************************************* ['aa', 'needs', 'therefore', 'will', 'need', 'to', 'increase', 'goal', 'rate', 'of', 'TF'] ******************************************************************************************* ['s', 'to', 'avoid'] ******************************************************************************************* ['underfeeding'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['Multivitamin', 'Mineral', 'supplement', 'vua', 'TF'] ******************************************************************************************* ['Tube', 'feeding', 'recommendations', 'Increase', 'TF', 'goal', 'rate', 'to', '75', 'mL', 'hr', '1800'] ******************************************************************************************* ['kcals/112', 'gr', 'aa'] ******************************************************************************************* ['BG', 'management', 'as', 'you', 'are'] ******************************************************************************************* ['Please', 'page', 'c/', "'s", 'Numeric', 'Identifier', '1684'] ******************************************************************************************* [] ******************************************************************************************* ['98851,Nutrition,"Patient', 'has', 'been', 'NPO', 'and/or', 'on', 'unsupplemented', 'clear', 'liquid', 'diet', 'for', '1'] ******************************************************************************************* ['days', 'If', 'patient', "'s", 'diet', 'is', 'not', 'able', 'to', 'be', 'advanced', 'and', 'tolerated'] ******************************************************************************************* ['Street', 'Address(1', '1511', 'for', 'nutrition', 'support'] ******************************************************************************************* ['Potential', 'for', 'nutrition', 'risk', 'Patient', 'being', 'monitored', 'Current'] ******************************************************************************************* ['intervention', 'if', 'any', 'listed', 'below'] ******************************************************************************************* ['Comments'] ******************************************************************************************* ['Pt', 's', 'p', 'LRRT', '4', '17', 'c', 'b', 'hypoxia', 'and', 'increased', 'O2', 'requirements', 'in', 'PACU', 'on'] ******************************************************************************************* ['clears', 'tolerating', 'well', 'Clinically', 'improving', 'possibly', 'transfer', 'to'] ******************************************************************************************* ['floor', 'soon'] ******************************************************************************************* ['If', 'unable', 'to', 'advance', 'diet', 'further', 'in', '24', '48hrs', 'patient', 'may', 'benefit', 'from'] ******************************************************************************************* ['nutrition', 'support'] ******************************************************************************************* ['Will', 'f', 'u', 'with', 'progress', 'po', 'tolerance'] ******************************************************************************************* ['Please', 'page', 'w/', 'questions', 'Numeric', 'Identifier', '1687'] ******************************************************************************************* ['12:11'] ******************************************************************************************* [] ******************************************************************************************* ['58054,Nutrition,"Comments'] ******************************************************************************************* ['Screening', 'per', 'hospital', 'nutrition', 'protocol', 'Noted', 'patient', 'is', 'comfort'] ******************************************************************************************* ['measures', 'only', 'No', 'nutrition', 'support', 'indicated', 'at', 'this', 'time', 'Will', 'sign'] ******************************************************************************************* ['off', 'Please', 'consult', 'if', 'needed', 'Numeric', 'Identifier', '2337'] ******************************************************************************************* [] ******************************************************************************************* ['99573,Nutrition,"Subjective'] ******************************************************************************************* ['patient', 'confused', 'unable', 'to', 'answer', 'questions', 'per', 'chart', 'patient', 'had'] ******************************************************************************************* ['difficulty', 'swallowing', 'PTA', 'd', 't', 'damaged', 'salivary', 'glands', 'from', 'XRT'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['168', 'cm'] ******************************************************************************************* ['98.2', 'kg'] ******************************************************************************************* ['34.9'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Adjusted', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['59', 'kg'] ******************************************************************************************* ['166'] ******************************************************************************************* ['68.8', 'kg'] ******************************************************************************************* ['Diagnosis', 'facial', 'fx'] ******************************************************************************************* ['PMH', 'breast', 'ca', 'tongue', 'ca', 'ovarian', 'ca', 'polymyalgia', 'NIDDM', 'vertigo', 'hx'] ******************************************************************************************* ['of', 'falls'] ******************************************************************************************* ['Food', 'allergies', 'and', 'intolerances', 'none', 'noted'] ******************************************************************************************* ['Pertinent', 'medications', 'RISS', 'IV', 'abx', 'protonix', 'KCl', '30', 'mEq', 'Dextrose'] ******************************************************************************************* ['5', '1/2', 'normal', 'saline', 'with', 'KCl', 'others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['206'] ******************************************************************************************* ['2181', '6', '5', '08:00', 'AM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['222'] ******************************************************************************************* ['2181', '6', '4', '08:00', 'PM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['11', 'mg', 'dL'] ******************************************************************************************* ['2181', '6', '4', '11:36', 'PM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['0.5', 'mg', 'dL'] ******************************************************************************************* ['2181', '6', '4', '11:36', 'PM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['134', 'mEq', 'L'] ******************************************************************************************* ['2181', '6', '4', '11:36', 'PM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['4.1', 'mEq', 'L'] ******************************************************************************************* ['2181', '6', '5', '09:13', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['98', 'mEq', 'L'] ******************************************************************************************* ['2181', '6', '4', '11:36', 'PM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['26', 'mEq', 'L'] ******************************************************************************************* ['2181', '6', '4', '11:36', 'PM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['6.5', 'units'] ******************************************************************************************* ['2181', '6', '3', '12:30', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['8.5', 'mg', 'dL'] ******************************************************************************************* ['2181', '6', '4', '11:36', 'PM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['2.3', 'mg', 'dL'] ******************************************************************************************* ['2181', '6', '4', '11:36', 'PM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['2.0', 'mg', 'dL'] ******************************************************************************************* ['2181', '6', '4', '11:36', 'PM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['9.2', 'K', 'uL'] ******************************************************************************************* ['2181', '6', '5', '12:03', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['10.9', 'g', 'dL'] ******************************************************************************************* ['2181', '6', '5', '12:03', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['32.7'] ******************************************************************************************* ['2181', '6', '5', '12:03', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'NPO'] ******************************************************************************************* ['GI', 'obese', '+', 'bowel', 'sounds'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['Obese', 'At', 'risk', 'for', 'malnutrition'] ******************************************************************************************* ['Pt', 'at', 'risk', 'due', 'to', 'NPO', 'hypocaloric', 'diet', 'trauma'] ******************************************************************************************* ['Estimated', 'Nutritional', 'Needs', 'based', 'on', 'adjusted', 'body', 'wt'] ******************************************************************************************* ['Calories', '1513', '1720', '22', '25', 'cal', 'kg'] ******************************************************************************************* ['Protein', '83', '103', '1.2', '1.5', 'g', 'kg'] ******************************************************************************************* ['Fluid', 'per', 'team'] ******************************************************************************************* ['Estimation', 'of', 'previous', 'intake', 'unknown'] ******************************************************************************************* ['Estimation', 'of', 'current', 'intake', 'Inadequate', 'd', 't', 'NPO', 'status'] ******************************************************************************************* ['Specifics', '78', 'year', 'old', 'female', 'admitted', 'from', 'outside', 'hospital', 'S', 'P', 'fall'] ******************************************************************************************* ['at', 'home', 'with', 'multiple', 'injuries', 'including', 'Le', 'Forte', 'fx', 'multiple', 'sinus'] ******************************************************************************************* ['fx', 'orbital', 'fx', 'facial', 'and', 'tongue', 'swelling', 'Patient', 'seen', 'by', 'SLP', 'on', '6', '4'] ******************************************************************************************* ['who', 'recommended', 'patient', 'remain', 'NPO', 'If', 'patient'] ******************************************************************************************* ['s', 'diet', 'can', 'not', 'be'] ******************************************************************************************* ['advanced', 'consider', 'initiating', 'tube', 'feedings', 'to', 'prevent', 'further'] ******************************************************************************************* ['nutritional', 'decline'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['If', 'diet', 'can', 'not', 'be', 'advanced', 'recommend', 'starting', 'tube', 'feedings', 'start', 'with'] ******************************************************************************************* ['Replete', 'with', 'Fiber', '15', 'ml', 'hr', 'advance', 'to', 'goal', 'of', '65', 'ml', 'hr', '=', '1560'] ******************************************************************************************* ['kcals/97', 'g', 'protein'] ******************************************************************************************* ['Check', 'residuals', 'q', '4', '6', 'hours', 'hold', 'if', 'greater', 'than', '150', 'cc'] ******************************************************************************************* ['Monitor', 'lytes', 'and', 'glucose', 'with', 'initiation', 'of', 'tube', 'feeding'] ******************************************************************************************* ['Change', 'to', 'non', 'dextrose', 'IV', 'fluids', 'once', 'tube', 'feedings', 'started'] ******************************************************************************************* ['Implement', 'any', 'SLP', 'recs'] ******************************************************************************************* ['Will', 'continue', 'to', 'follow', 'page', 'Numeric', 'Identifier', '1372', 'with', 'questions'] ******************************************************************************************* [] ******************************************************************************************* ['40461,Nutrition,"Subjective'] ******************************************************************************************* ['oriented', 'x1'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['178', 'cm'] ******************************************************************************************* ['63', 'kg'] ******************************************************************************************* ['74.9', 'kg', '2113', '2', '3', '04:00', 'AM'] ******************************************************************************************* ['19.9'] ******************************************************************************************* ['Pertinent', 'medications', 'Ranitidine', 'Multi', 'vitamin', 'ABX', 'Folic', 'Acid'] ******************************************************************************************* ['Thiamine', 'Coumadin', 'Lasix', 'Colace', 'held', 'KCl', '20mEq', 'repletion', 'x2'] ******************************************************************************************* ['Magnesium', 'sulfate', '2', 'g', 'repletion', 'Heparin', 'drip'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['105', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['127'] ******************************************************************************************* ['2113', '2', '3', '12:00', 'PM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['25', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['1.8', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['142', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.9', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['110', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['25', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['65', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['PO2', 'venous'] ******************************************************************************************* ['48', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['30', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['PCO2', 'venous'] ******************************************************************************************* ['33', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.46', 'units'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['pH', 'venous'] ******************************************************************************************* ['7.43', 'units'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.5', 'units'] ******************************************************************************************* ['2113', '2', '1', '07:16', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['22', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'venous'] ******************************************************************************************* ['23', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['2.1', 'g', 'dL'] ******************************************************************************************* ['2113', '2', '1', '02:44', 'PM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['7.5', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['3.0', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Ionized', 'Calcium'] ******************************************************************************************* ['1.08', 'mmol', 'L'] ******************************************************************************************* ['2113', '1', '30', '11:46', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['2.3', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['ALT'] ******************************************************************************************* ['23', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Alkaline', 'Phosphate'] ******************************************************************************************* ['51', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['AST'] ******************************************************************************************* ['24', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Amylase'] ******************************************************************************************* ['40', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Total', 'Bilirubin'] ******************************************************************************************* ['0.3', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Triglyceride'] ******************************************************************************************* ['120', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['9.3', 'K', 'uL'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['8.9', 'g', 'dL'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['27.0'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Diet', 'NPO'] ******************************************************************************************* ['Calorie', 'counts', '2', '1', '17', '18'] ******************************************************************************************* ['GI', 'soft', '+', 'bowel', 'sounds', '500ml', 'stool', 'today'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['Estimation', 'of', 'current', 'intake', 'Inadequate'] ******************************************************************************************* ['Specifics'] ******************************************************************************************* ['49', 'year', 'old', 'male', 'with', 'mitral', 'valve', 'endocarditis', 'preop', 'stroke', 's', 'p', 'MVR'] ******************************************************************************************* ['29', 'mm', 'First', 'Name8', 'NamePattern2', 'First', 'Name4', 'NamePattern1', '1104', 'Last', 'Name', 'NamePattern1', '1105', 'debridement', 'of', 'aortic', 'valve', '1', '27', 'Patient', 'with'] ******************************************************************************************* ['prolonged', 'poor', 'po'] ******************************************************************************************* ['s', 'during', 'admit', 'Was', 'on', 'ground', 'solids', '+', 'thin', 'liquid'] ******************************************************************************************* ['diet', 'refusing', 'po'] ******************************************************************************************* ['s', 'at', 'times', 's', 'p', 'calories', 'counts'] ******************************************************************************************* ['880', 'calories', '2', '1'] ******************************************************************************************* ['and', '270', 'calories', '2', '2', 'Seen', 'for', 'video', 'swallow', 'evaluation', 'this', 'AM'] ******************************************************************************************* ['SLP', 'recommend', 'NPO', 'Per', 'discussion', 'with', 'PA'] ******************************************************************************************* ['plan', 'for', 'PEG', 'placement', 'as'] ******************************************************************************************* ['previously', 'unable', 'to', 'place', 'NGT', 'and', 'feel', 'that', 'patient', 'will', 'pull', 'it', 'out'] ******************************************************************************************* ['Agree', 'with', 'PEG', 'for', 'long', 'term', 'nutrition', 'support', 'to', 'prevent', 'further'] ******************************************************************************************* ['nutritional', 'decline', 'and', 'optimize', 'nutrition', 'for', 'post', 'op', 'healing', 'Noted'] ******************************************************************************************* ['multiple', 'lyte', 'repletions'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['Current', 'diet', 'nutrition', 'support', 'is', 'appropriate', 'continue'] ******************************************************************************************* ['NPO', 'per', 'SLP', 'recommendations'] ******************************************************************************************* ['o', 'SLP', 'follow', 'up', 'when', 'appropriate'] ******************************************************************************************* ['Tube', 'feeding', 'recommendations', 'Agree', 'with', 'PEG'] ******************************************************************************************* ['o', 'Once', 'feeding', 'tube', 'placed', 'recommend', 'begin', 'Isosource', '1.5'] ******************************************************************************************* ['20ml', 'hr', 'advance', 'as', 'tolerated', 'to', 'goal', 'of', '45ml', 'hr', '=', '1620', 'calories', 'and'] ******************************************************************************************* ['73', 'g', 'protein'] ******************************************************************************************* ['Check', 'residuals', 'hold', 'tube', 'feed', 'if', 'greater', 'than', '200ml'] ******************************************************************************************* ['Multivitamin', 'Mineral', 'supplement', 'continue', 'current'] ******************************************************************************************* ['Check', 'chemistry', '10', 'panel', 'daily'] ******************************************************************************************* ['o', 'Replete', 'lytes', 'PRN'] ******************************************************************************************* ['Will', 'follow', 'page', 'if', 'questions', 'Numeric', 'Identifier', '606'] ******************************************************************************************* [] ******************************************************************************************* ['40461,Nutrition,"Subjective'] ******************************************************************************************* ['Patient', 'oob', 'tube', 'feed', 'running', 'at', '40', 'ml', 'hr'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Pertinent', 'medications', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['119'] ******************************************************************************************* ['2113', '2', '8', '08:00', 'AM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['150'] ******************************************************************************************* ['2113', '2', '7', '10:00', 'PM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['31', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '8', '02:50', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['2.0', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '8', '02:50', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['143', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '8', '02:50', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.4', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '8', '07:52', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['109', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '8', '02:50', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['25', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '8', '02:50', 'AM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['65', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['PO2', 'venous'] ******************************************************************************************* ['48', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['30', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['PCO2', 'venous'] ******************************************************************************************* ['33', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.46', 'units'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['pH', 'venous'] ******************************************************************************************* ['7.43', 'units'] ******************************************************************************************* ['2113', '2', '7', '05:19', 'PM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.5', 'units'] ******************************************************************************************* ['2113', '2', '1', '07:16', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['22', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'venous'] ******************************************************************************************* ['23', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['2.2', 'g', 'dL'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['7.8', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['4.0', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Ionized', 'Calcium'] ******************************************************************************************* ['1.07', 'mmol', 'L'] ******************************************************************************************* ['2113', '2', '7', '05:19', 'PM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['2.1', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '8', '07:52', 'AM'] ******************************************************************************************* ['ALT'] ******************************************************************************************* ['21', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Alkaline', 'Phosphate'] ******************************************************************************************* ['50', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['AST'] ******************************************************************************************* ['23', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Amylase'] ******************************************************************************************* ['45', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Total', 'Bilirubin'] ******************************************************************************************* ['0.4', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Triglyceride'] ******************************************************************************************* ['120', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['10.1', 'K', 'uL'] ******************************************************************************************* ['2113', '2', '8', '02:50', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['8.3', 'g', 'dL'] ******************************************************************************************* ['2113', '2', '8', '02:50', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['26.1'] ******************************************************************************************* ['2113', '2', '8', '02:50', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Replete', 'with', 'fiber', 'Full'] ******************************************************************************************* ['strength'] ******************************************************************************************* ['Starting', 'rate', '40', 'ml', 'hr', 'Advance', 'rate', 'by', '20', 'ml', 'q6h', 'Goal', 'rate', '70', 'ml', 'hr'] ******************************************************************************************* ['Residual', 'Check', 'q4h', 'Hold', 'feeding', 'for', 'residual', '>', '=', '200', 'ml'] ******************************************************************************************* ['Flush', 'w/', '30', 'ml', 'water', 'q8h'] ******************************************************************************************* ['GI', 'Abdominal', 'Soft', 'Non', 'distended', 'Non', 'tender', 'Bowel', 'sounds', 'present'] ******************************************************************************************* ['PEG', 'site', 'clean', 'and', 'dry'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['49', 'year', 'old', 'male', 's', 'p', 'PEG', 'placement', 'yesterday', 'tube', 'feed', 'started'] ******************************************************************************************* ['yesterday', 'tolerated', 'Isosource', '1.5', 'well', 'tube', 'feed', 'ordered', 'changed', 'to'] ******************************************************************************************* ['Replete', 'with', 'fiber', 'this', 'morning', 'spoke', 'to', 'team', 'does', 'not', 'want', 'patient'] ******************************************************************************************* ['on', 'special', 'tube', 'feed', 'recommend', 'change', 'to', 'Fibersource', 'HN', 'as', 'current'] ******************************************************************************************* ['formula', 'provides', 'excess', 'amount', 'of', 'protein', 'Noted', 'discharge', 'planning', 'in'] ******************************************************************************************* ['progress'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['Tube', 'feeding', 'Fibersource', 'HN', 'goal', '60ml', 'hr', '1728kcal/76', 'g'] ******************************************************************************************* ['protein'] ******************************************************************************************* ['Check', 'chemistry', '10', 'panel', 'daily', 'replete', 'prn'] ******************************************************************************************* ['Continue', 'BS', 'management'] ******************************************************************************************* ['Numeric', 'Identifier', '943', 'if', 'has', 'question'] ******************************************************************************************* [] ******************************************************************************************* ['40461,Nutrition,"Subjective'] ******************************************************************************************* ['Patient', 'asleep'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['178', 'cm'] ******************************************************************************************* ['63', 'kg'] ******************************************************************************************* ['70.8', 'kg', '2113', '2', '7', '04:00', 'AM'] ******************************************************************************************* ['19.9'] ******************************************************************************************* ['Pertinent', 'medications', 'Multiple', 'Vitamins', 'Furosemide', 'Docusate', 'Sodium'] ******************************************************************************************* ['others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['157', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '7', '04:00', 'AM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['158'] ******************************************************************************************* ['2113', '2', '7', '06:00', 'AM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['33', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '7', '04:00', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['1.9', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '7', '04:00', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['145', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '7', '04:00', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.7', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '7', '04:00', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['111', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '7', '04:00', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['24', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '7', '04:00', 'AM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['65', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['PO2', 'venous'] ******************************************************************************************* ['48', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['30', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['PCO2', 'venous'] ******************************************************************************************* ['33', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.46', 'units'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['pH', 'venous'] ******************************************************************************************* ['7.43', 'units'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.5', 'units'] ******************************************************************************************* ['2113', '2', '1', '07:16', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['22', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'venous'] ******************************************************************************************* ['23', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['2.2', 'g', 'dL'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['7.8', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['4.0', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Ionized', 'Calcium'] ******************************************************************************************* ['1.08', 'mmol', 'L'] ******************************************************************************************* ['2113', '1', '30', '11:46', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['2.0', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '6', '11:00', 'PM'] ******************************************************************************************* ['ALT'] ******************************************************************************************* ['21', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Alkaline', 'Phosphate'] ******************************************************************************************* ['50', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['AST'] ******************************************************************************************* ['23', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Amylase'] ******************************************************************************************* ['45', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Total', 'Bilirubin'] ******************************************************************************************* ['0.4', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '6', '04:05', 'AM'] ******************************************************************************************* ['Triglyceride'] ******************************************************************************************* ['120', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['12.3', 'K', 'uL'] ******************************************************************************************* ['2113', '2', '7', '04:00', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['8.8', 'g', 'dL'] ******************************************************************************************* ['2113', '2', '7', '04:00', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['26.9'] ******************************************************************************************* ['2113', '2', '7', '04:00', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Non', 'Standard', 'TPN', 'For', 'Date'] ******************************************************************************************* ['2113', '2', '6', '1600ml', '270drextrose/80protein/35fat'] ******************************************************************************************* ['Replete', 'with', 'fiber', 'Full', 'strength'] ******************************************************************************************* ['Starting', 'rate', '10', 'ml', 'hr', 'Advance', 'rate', 'by', '10', 'ml', 'q6h', 'Goal', 'rate', '60', 'ml', 'hr'] ******************************************************************************************* ['Residual', 'Check', 'q4h', 'Hold', 'feeding', 'for', 'residual', '>', '=', '200', 'ml'] ******************************************************************************************* ['Flush', 'w/', '30', 'ml', 'water', 'q8h'] ******************************************************************************************* ['GI', 'Abdominal', 'Soft', 'Non', 'distended', 'Non', 'tender', 'Bowel', 'sounds', 'present'] ******************************************************************************************* ['PEG', 'site', 'clean', 'and', 'dry', 'Peg', 'to', 'gravity', 'drainage'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['49', 'year', 'old', 'male', 'with', 'Mitral', 'valve', 'endocarditis', 'preop', 'stroke', 's', 'p', 'MVR'] ******************************************************************************************* ['and', 'debridement', 'of', 'aortic', 'valve', '1', '27', 'patient', 'failed', 'S', 'S', 'evaluation'] ******************************************************************************************* ['TPN', 'started', 'over', 'the', 'weekend', 'while', 'awaiting', 'PEG', 'PEG', 'placed'] ******************************************************************************************* ['yesterday', 'plan', 'to', 'start', 'tube', 'feeds', 'today', 'current', 'tube', 'feed', 'order', 'not'] ******************************************************************************************* ['meeting', 'patient'] ******************************************************************************************* ['s', 'estimated', 'need', 'Noted', 'patient', 'with', 'post', 'op', 'fluid'] ******************************************************************************************* ['gain', 'recommend', 'fluid', 'restricted', 'formula'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['Consider', 'ordering', 'day', '1', 'TPN', 'tonight', 'while', 'slowly', 'advancing'] ******************************************************************************************* ['tube', 'feed'] ******************************************************************************************* ['Tube', 'feeding', 'Isosource', '1.5cal', 'goal', '45ml', 'hr', '1620kcal/73', 'g'] ******************************************************************************************* ['protein'] ******************************************************************************************* ['Start', 'tube', 'feed', 'at', '15ml', 'hr', 'and', 'adv', 'slowly', 'as', 'tol'] ******************************************************************************************* ['Check', 'chemistry', '10', 'panel', 'daily', 'replete', 'prn'] ******************************************************************************************* ['Continue', 'BS', 'management'] ******************************************************************************************* ['Numeric', 'Identifier', '943', 'if', 'has', 'question'] ******************************************************************************************* [] ******************************************************************************************* ['40461,Nutrition,"Subjective'] ******************************************************************************************* ['patient', 'sleeping'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['178', 'cm'] ******************************************************************************************* ['63', 'kg'] ******************************************************************************************* ['74.9', 'kg', '2113', '2', '3', '04:00', 'AM'] ******************************************************************************************* ['19.9'] ******************************************************************************************* ['Pertinent', 'medications', 'D5', '@10', 'ml', 'hr', 'KCl', '40', 'mEq', 'repletion', 'RISS', 'IV'] ******************************************************************************************* ['abx', 'lansoprazole', 'famotidine', 'others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['73'] ******************************************************************************************* ['2113', '2', '4', '12:00', 'PM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['135'] ******************************************************************************************* ['2113', '2', '4', '12:00', 'AM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['25', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '4', '03:42', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['1.6', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '4', '03:42', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['140', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '4', '03:42', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.5', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '4', '03:42', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['108', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '4', '03:42', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['22', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '4', '03:42', 'AM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['65', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['PO2', 'venous'] ******************************************************************************************* ['48', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['30', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['PCO2', 'venous'] ******************************************************************************************* ['33', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.46', 'units'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['pH', 'venous'] ******************************************************************************************* ['7.43', 'units'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.5', 'units'] ******************************************************************************************* ['2113', '2', '1', '07:16', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['22', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'venous'] ******************************************************************************************* ['23', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['2.1', 'g', 'dL'] ******************************************************************************************* ['2113', '2', '1', '02:44', 'PM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['7.3', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '4', '03:42', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['3.1', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '4', '03:42', 'AM'] ******************************************************************************************* ['Ionized', 'Calcium'] ******************************************************************************************* ['1.08', 'mmol', 'L'] ******************************************************************************************* ['2113', '1', '30', '11:46', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['2.0', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '4', '03:42', 'AM'] ******************************************************************************************* ['ALT'] ******************************************************************************************* ['23', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Alkaline', 'Phosphate'] ******************************************************************************************* ['51', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['AST'] ******************************************************************************************* ['24', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Amylase'] ******************************************************************************************* ['40', 'IU', 'L'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Total', 'Bilirubin'] ******************************************************************************************* ['0.3', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '3', '05:24', 'AM'] ******************************************************************************************* ['Triglyceride'] ******************************************************************************************* ['120', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['13.4', 'K', 'uL'] ******************************************************************************************* ['2113', '2', '4', '03:42', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['9.8', 'g', 'dL'] ******************************************************************************************* ['2113', '2', '4', '03:42', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['29.7'] ******************************************************************************************* ['2113', '2', '4', '03:42', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'NPO'] ******************************************************************************************* ['GI', 'soft', 'hypoactive', 'bowel', 'sounds'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['Specifics', 'Patient', 's', 'p', 'video', 'swallow', '2', '3', 'which', 'recommended', 'patient', 'be'] ******************************************************************************************* ['NPO', 'Received', 'consult', 'for', 'PPN', 'recommendations', 'Per', 'discussion', 'with', 'PA'] ******************************************************************************************* ['plan', 'is', 'for', 'PEG', 'placement', 'on', 'Monday', 'and', 'to', 'supplement', 'nutrition', 'with'] ******************************************************************************************* ['parenteral', 'nutrition', 'until', 'PEG', 'is', 'able', 'to', 'be', 'used', 'Patient', 'with', 'PICC'] ******************************************************************************************* ['Day', '1', 'TPN', 'ordered', 'to', 'start', 'tonight', 'NGT', 'was', 'attempted', 'earlier', 'in', 'week'] ******************************************************************************************* ['and', 'was', 'unable', 'to', 'placed', 'and', 'team', 'thinks', 'patient', 'would', 'pull', 'it', 'out'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['1', 'Day', '1', 'TPN', 'tonight'] ******************************************************************************************* ['2', 'Pending', 'glycemic', 'control', 'advance', 'to', 'goal', 'TPN', '1.6L', '270', 'g'] ******************************************************************************************* ['dextrose/80', 'g', 'amino', 'acids/35', 'g', 'lipids)=', '1588', 'kcals'] ******************************************************************************************* ['3', 'Check', 'TG', 'hold', 'lipids', 'if', 'greater', 'than', '400'] ******************************************************************************************* ['4', 'Once', 'PEG', 'placed', 'start', 'with', 'Isosource', 'HN', '15', 'ml', 'hr', 'advance', 'to'] ******************************************************************************************* ['goal', 'of', '45', 'ml', 'hr', '=', '1620', 'kcals/', '73', 'g', 'protein'] ******************************************************************************************* ['5', 'Will', 'follow', 'page', 'Numeric', 'Identifier', '1372', 'with', 'questions'] ******************************************************************************************* [] ******************************************************************************************* ['40461,Nutrition,"Subjective'] ******************************************************************************************* ['Patient', 'asleep', 'Name8', 'MD', '77', 'RN', 'patient', 'refused', 'all', 'po', 'food', 'or', 'supplements'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['178', 'cm'] ******************************************************************************************* ['63', 'kg'] ******************************************************************************************* ['70.5', 'kg', '2113', '1', '19', '08:00', 'AM'] ******************************************************************************************* ['up', 'due', 'to', 'fluid'] ******************************************************************************************* ['19.9'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Adjusted', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['75.3', 'kg'] ******************************************************************************************* ['119'] ******************************************************************************************* ['63', 'kg'] ******************************************************************************************* ['100'] ******************************************************************************************* ['Diagnosis', 'MITRAL', 'VALVE', 'ENDOCARDITIS'] ******************************************************************************************* ['PMHx', 'None', 'no', 'medical', 'care', 'x', '30', 'years'] ******************************************************************************************* ['Food', 'allergies', 'and', 'intolerances', 'not', 'available'] ******************************************************************************************* ['Pertinent', 'medications', 'Furosemide', 'Milrinone', 'Multivitamins', 'Thiamine'] ******************************************************************************************* ['FoLIC', 'Acid', 'Nicotine', 'Patch', 'Heparin', 'Docusate', 'Sodium', 'Nafcillin'] ******************************************************************************************* ['Potassium', 'Chloride', 'others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['117', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['25', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['1.5', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['137', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.3', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['103', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['22', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['PO2', 'venous'] ******************************************************************************************* ['145', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '15', '04:51', 'PM'] ******************************************************************************************* ['PCO2', 'venous'] ******************************************************************************************* ['34', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '15', '04:51', 'PM'] ******************************************************************************************* ['pH', 'venous'] ******************************************************************************************* ['7.45', 'units'] ******************************************************************************************* ['2113', '1', '15', '04:51', 'PM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.0', 'units'] ******************************************************************************************* ['2113', '1', '18', '12:03', 'PM'] ******************************************************************************************* ['CO2', 'Calc', 'venous'] ******************************************************************************************* ['24', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '15', '04:51', 'PM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['1.9', 'g', 'dL'] ******************************************************************************************* ['2113', '1', '18', '07:15', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['7.1', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['4.8', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['1.9', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['ALT'] ******************************************************************************************* ['36', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Alkaline', 'Phosphate'] ******************************************************************************************* ['44', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['AST'] ******************************************************************************************* ['54', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Total', 'Bilirubin'] ******************************************************************************************* ['0.4', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['13.0', 'K', 'uL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['11.8', 'g', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['35.2'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Regular', 'Supplement', 'Ensure'] ******************************************************************************************* ['Plus', 'breakfast', 'lunch', 'dinner'] ******************************************************************************************* ['GI', 'Abdominal', 'Soft', 'Non', 'tender', 'Bowel', 'sounds', 'present'] ******************************************************************************************* ['Extremities', 'Right', 'lower', 'extremity', 'edema', 'Absent', 'Left', 'lower', 'extremity'] ******************************************************************************************* ['edema'] ******************************************************************************************* ['Skin', 'Warm', 'Rash', 'upper', 'and', 'lower', 'ext', 'occ', 'petechiae'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['At', 'risk', 'for', 'malnutrition'] ******************************************************************************************* ['Patient', 'at', 'risk', 'due', 'to', 'Low', 'po', 'intake', 'current', 'illness', 'head', 'CT', 'showed', 'multipl'] ******************************************************************************************* ['e', 'small', 'non', 'hemorrhagic'] ******************************************************************************************* ['infarcts', 'suspicious', 'for', 'septic', 'emboli'] ******************************************************************************************* ['Estimated', 'Nutritional', 'Needs'] ******************************************************************************************* ['Calories', '1575', '1764', 'BEE', 'x', 'or', '25', '28', 'cal', 'kg'] ******************************************************************************************* ['Protein', '76', '88', '1.2', '1.4', 'g', 'kg'] ******************************************************************************************* ['Fluid', 'per', 'team'] ******************************************************************************************* ['Calculations', 'based', 'on', 'Admit', 'weight'] ******************************************************************************************* ['Estimation', 'of', 'previous', 'intake', 'Inadequate'] ******************************************************************************************* ['Estimation', 'of', 'current', 'intake', 'Inadequate'] ******************************************************************************************* ['Specifics'] ******************************************************************************************* ['49', 'year', 'old', 'male', 'found', 'to', 'have', 'staphylococcus', 'aureus', 'bacterial'] ******************************************************************************************* ['endocarditis', 'with', 'severe', 'mitral', 'regurgitation', '3', '21', 'mitral', 'valve'] ******************************************************************************************* ['vegetations', 'and', 'flail', 'leaflet', 'Patient', 'transferred', 'from', 'Hospital', 'Hospital1', '5', 'for', 'CT', 'surgery', 'evaluation', 'and', 'further', 'management'] ******************************************************************************************* ['Patient', 's', 'p', 'speech', 'and', 'swallow', 'evaluation', 'okay', 'to', 'have', 'regular', 'diet'] ******************************************************************************************* ['yet', 'patient', 'refused', 'to', 'take', 'pos', 'spoke', 'to', 'team', 'this', 'morning', 'team'] ******************************************************************************************* ['considering', 'NGT', 'placement'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['Po', 'as', 'tolerance'] ******************************************************************************************* ['Tube', 'feeding', 'recommendations', 'Nutren', 'Pulmonary', 'goal', '45ml', 'hr'] ******************************************************************************************* ['1620kcal/73.4', 'g', 'protein'] ******************************************************************************************* ['Monitor', 'tube', 'feed', 'tolerance'] ******************************************************************************************* ['Check', 'chemistry', '10', 'panel', 'daily', 'replete', 'as', 'you', 'are', 'doing'] ******************************************************************************************* ['Consider', 'adding', 'phos', 'binder', 'if', 'serum', 'phos', 'remains', 'elevated'] ******************************************************************************************* ['Start', 'regular', 'insulin', 'sliding', 'scale', 'if', 'serum', 'glucose', 'greater'] ******************************************************************************************* ['than', '150', 'mg', 'dL'] ******************************************************************************************* ['Other', 'Numeric', 'Identifier', '943', 'if', 'has', 'question'] ******************************************************************************************* [] ******************************************************************************************* ['40461,Nutrition,"Subjective'] ******************************************************************************************* ['Patient', 'asleep', 'Name8', 'MD', '77', 'RN', 'patient', 'refused', 'all', 'po', 'food', 'or', 'supplements'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['178', 'cm'] ******************************************************************************************* ['63', 'kg'] ******************************************************************************************* ['70.5', 'kg', '2113', '1', '19', '08:00', 'AM'] ******************************************************************************************* ['up', 'due', 'to', 'fluid'] ******************************************************************************************* ['19.9'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Ideal', 'body', 'weight'] ******************************************************************************************* ['Adjusted', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['Usual', 'body', 'weight'] ******************************************************************************************* ['75.3', 'kg'] ******************************************************************************************* ['119'] ******************************************************************************************* ['63', 'kg'] ******************************************************************************************* ['100'] ******************************************************************************************* ['Diagnosis', 'MITRAL', 'VALVE', 'ENDOCARDITIS'] ******************************************************************************************* ['PMHx', 'None', 'no', 'medical', 'care', 'x', '30', 'years'] ******************************************************************************************* ['Food', 'allergies', 'and', 'intolerances', 'not', 'available'] ******************************************************************************************* ['Pertinent', 'medications', 'Furosemide', 'Milrinone', 'Multivitamins', 'Thiamine'] ******************************************************************************************* ['FoLIC', 'Acid', 'Nicotine', 'Patch', 'Heparin', 'Docusate', 'Sodium', 'Nafcillin'] ******************************************************************************************* ['Potassium', 'Chloride', 'others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['117', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['25', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['1.5', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['137', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.3', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['103', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['22', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['PO2', 'venous'] ******************************************************************************************* ['145', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '15', '04:51', 'PM'] ******************************************************************************************* ['PCO2', 'venous'] ******************************************************************************************* ['34', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '15', '04:51', 'PM'] ******************************************************************************************* ['pH', 'venous'] ******************************************************************************************* ['7.45', 'units'] ******************************************************************************************* ['2113', '1', '15', '04:51', 'PM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.0', 'units'] ******************************************************************************************* ['2113', '1', '18', '12:03', 'PM'] ******************************************************************************************* ['CO2', 'Calc', 'venous'] ******************************************************************************************* ['24', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '15', '04:51', 'PM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['1.9', 'g', 'dL'] ******************************************************************************************* ['2113', '1', '18', '07:15', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['7.1', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['4.8', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['1.9', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['ALT'] ******************************************************************************************* ['36', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Alkaline', 'Phosphate'] ******************************************************************************************* ['44', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['AST'] ******************************************************************************************* ['54', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Total', 'Bilirubin'] ******************************************************************************************* ['0.4', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['13.0', 'K', 'uL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['11.8', 'g', 'dL'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['35.2'] ******************************************************************************************* ['2113', '1', '20', '02:36', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Regular', 'Supplement', 'Ensure'] ******************************************************************************************* ['Plus', 'breakfast', 'lunch', 'dinner'] ******************************************************************************************* ['GI', 'Abdominal', 'Soft', 'Non', 'tender', 'Bowel', 'sounds', 'present'] ******************************************************************************************* ['Extremities', 'Right', 'lower', 'extremity', 'edema', 'Absent', 'Left', 'lower', 'extremity'] ******************************************************************************************* ['edema'] ******************************************************************************************* ['Skin', 'Warm', 'Rash', 'upper', 'and', 'lower', 'ext', 'occ', 'petechiae'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['At', 'risk', 'for', 'malnutrition'] ******************************************************************************************* ['Patient', 'at', 'risk', 'due', 'to', 'Low', 'po', 'intake', 'current', 'illness', 'head', 'CT', 'showed', 'multipl'] ******************************************************************************************* ['e', 'small', 'non', 'hemorrhagic'] ******************************************************************************************* ['infarcts', 'suspicious', 'for', 'septic', 'emboli'] ******************************************************************************************* ['Estimated', 'Nutritional', 'Needs'] ******************************************************************************************* ['Calories', '1575', '1764', 'BEE', 'x', 'or', '25', '28', 'cal', 'kg'] ******************************************************************************************* ['Protein', '76', '88', '1.2', '1.4', 'g', 'kg'] ******************************************************************************************* ['Fluid', 'per', 'team'] ******************************************************************************************* ['Calculations', 'based', 'on', 'Admit', 'weight'] ******************************************************************************************* ['Estimation', 'of', 'previous', 'intake', 'Inadequate'] ******************************************************************************************* ['Estimation', 'of', 'current', 'intake', 'Inadequate'] ******************************************************************************************* ['Specifics'] ******************************************************************************************* ['49', 'year', 'old', 'male', 'found', 'to', 'have', 'staphylococcus', 'aureus', 'bacterial'] ******************************************************************************************* ['endocarditis', 'with', 'severe', 'mitral', 'regurgitation', '3', '21', 'mitral', 'valve'] ******************************************************************************************* ['vegetations', 'and', 'flail', 'leaflet', 'Patient', 'transferred', 'from', 'Hospital', 'Hospital1', '5', 'for', 'CT', 'surgery', 'evaluation', 'and', 'further', 'management'] ******************************************************************************************* ['Patient', 's', 'p', 'speech', 'and', 'swallow', 'evaluation', 'okay', 'to', 'have', 'regular', 'diet'] ******************************************************************************************* ['yet', 'patient', 'refused', 'to', 'take', 'pos', 'spoke', 'to', 'team', 'this', 'morning', 'team'] ******************************************************************************************* ['considering', 'NGT', 'placement'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['Po', 'as', 'tolerance'] ******************************************************************************************* ['Tube', 'feeding', 'recommendations', 'Nutren', 'Pulmonary', 'goal', '45ml', 'hr'] ******************************************************************************************* ['1620kcal/73.4', 'g', 'protein'] ******************************************************************************************* ['Monitor', 'tube', 'feed', 'tolerance'] ******************************************************************************************* ['Check', 'chemistry', '10', 'panel', 'daily', 'replete', 'as', 'you', 'are', 'doing'] ******************************************************************************************* ['Consider', 'adding', 'phos', 'binder', 'if', 'serum', 'phos', 'remains', 'elevated'] ******************************************************************************************* ['Start', 'regular', 'insulin', 'sliding', 'scale', 'if', 'serum', 'glucose', 'greater'] ******************************************************************************************* ['than', '150', 'mg', 'dL'] ******************************************************************************************* ['Other', 'Numeric', 'Identifier', '943', 'if', 'has', 'question'] ******************************************************************************************* ['Protected', 'Section'] ******************************************************************************************* ['Cardiology', 'Teaching', 'Physician', 'Note'] ******************************************************************************************* ['On', 'this', 'day', 'I', 'saw', 'examined', 'and', 'was', 'physically', 'present', 'with', 'the'] ******************************************************************************************* ['resident', 'fellow', 'for', 'the', 'key', 'portions', 'of', 'the', 'services', 'provided', 'I'] ******************************************************************************************* ['agree', 'with', 'the', 'above', 'note', 'and', 'plans'] ******************************************************************************************* ['I', 'would', 'add', 'the', 'following', 'remarks'] ******************************************************************************************* ['Medical', 'Decision', 'Making'] ******************************************************************************************* ['Patient', 'slowly', 'improving', 'the', 'am', 'after', 'aggressive', 'diuresis', 'and'] ******************************************************************************************* ['initiation', 'of', 'Milrinone', 'He', 'is', 'less', 'dyspneic', 'and', 'saturations', 'are', 'in', 'the'] ******************************************************************************************* ['95', '96', 'range', 'Renal', 'service', 'feels', 'ARF', 'is', 'multifactorial', 'and', 'sediment', 'is'] ******************************************************************************************* ['c', 'w', 'ATM', 'Createnine', 'is', 'stable', 'today', 'at', '1.5', 'He', 'is', 'speaking', 'clearly', 'but'] ******************************************************************************************* ['somnolent', 'and', 'wife', 'Name', 'NI', '1880', 'feels', 'this', 'is', 'from', 'not', 'sleeping', 'last', 'night'] ******************************************************************************************* ['WBC', 'down', 'to', '13', 'K', 'from', '14', 'K', 'yesterday', 'ID', 'recommends', 'continuing', 'Nafcillin'] ******************************************************************************************* ['with', 'bllod', 'cultures', 'with', 'fever', 'spikes', 'Source', 'of', 'fevers', 'are', 'unclear', 'now'] ******************************************************************************************* ['and', 'we', 'may', 'need', 'to', 'image', 'his', 'abdomen', 'as', 'he', 'complains', 'of', 'intermittent'] ******************************************************************************************* ['abdominal', 'pain', 'C-[**Doctor', 'First', 'Name', '91', 'continues', 'to', 'follow', 'closely', 'and', 'would', 'like', 'to'] ******************************************************************************************* ['delay', 'surgery', 'for', 'as', 'long', 'as', 'possible'] ******************************************************************************************* ['Protected', 'Section', 'Addendum', 'Entered', 'By:[**Name', 'NI', 'Last', 'Name', 'NamePattern1', 'MD'] ******************************************************************************************* ['on:[**2113', '1', '20', '05:48', 'PM'] ******************************************************************************************* [] ******************************************************************************************* ['40461,Nutrition,"Subjective', 'Did', 'not', 'speak', 'with', 'patient'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['178', 'cm'] ******************************************************************************************* ['63', 'kg'] ******************************************************************************************* ['72', 'kg', '2113', '1', '22', '10:00', 'AM'] ******************************************************************************************* ['19.9'] ******************************************************************************************* ['Pertinent', 'medications', 'Milrinone', 'protonix', 'abx', 'others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['98', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['27', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['1.0', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['137', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['4.3', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['107', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['19', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['61', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '22', '12:22', 'AM'] ******************************************************************************************* ['PO2', 'venous'] ******************************************************************************************* ['48', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['31', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '22', '12:22', 'AM'] ******************************************************************************************* ['PCO2', 'venous'] ******************************************************************************************* ['33', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.37', 'units'] ******************************************************************************************* ['2113', '1', '22', '12:22', 'AM'] ******************************************************************************************* ['pH', 'venous'] ******************************************************************************************* ['7.43', 'units'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.0', 'units'] ******************************************************************************************* ['2113', '1', '20', '06:24', 'PM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['19', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '22', '12:22', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'venous'] ******************************************************************************************* ['23', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['2.1', 'g', 'dL'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['7.6', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['3.8', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['2.0', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['ALT'] ******************************************************************************************* ['27', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Alkaline', 'Phosphate'] ******************************************************************************************* ['50', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['AST'] ******************************************************************************************* ['27', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Total', 'Bilirubin'] ******************************************************************************************* ['0.3', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['20.7', 'K', 'uL'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['12.9', 'g', 'dL'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['39.5'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Diet', 'Regular/', 'heart', 'healthy'] ******************************************************************************************* ['with', 'ensure', 'plus', 'TID'] ******************************************************************************************* ['GI', 'abd', 'soft', 'bowel', 'sounds', 'present'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['49', 'year', 'old', 'male', 'found', 'to', 'have', 'staphylococcus', 'aureus', 'bacterial'] ******************************************************************************************* ['endocarditis', 'with', 'severe', 'mitral', 'regurgitation', '3', '21', 'mitral', 'valve'] ******************************************************************************************* ['vegetations', 'and', 'flail', 'leaflet', 'Patient', 'transferred', 'from', 'Hospital', 'to', 'Hospital1', '5', 'for', 'CT', 'surgery', 'evaluation', 'and', 'further', 'management'] ******************************************************************************************* ['Patient', 's', 'p', 'speech', 'and', 'swallow', 'evaluation', 'okay', 'to', 'have', 'regular', 'diet'] ******************************************************************************************* ['yet', 'patient', 'is', 'only', 'taking', 'small', 'amounts', 'of', 'po'] ******************************************************************************************* ['s', 'due', 'to', 'mental', 'status'] ******************************************************************************************* ['Team', 'is', 'planning', 'to', 'place', 'an', 'NGT', 'for', 'start', 'of', 'tube', 'feeds', 'Tube'] ******************************************************************************************* ['feeding', 'are', 'recommendations', 'below', 'these', 'can', 'be', 'adjusted', 'based', 'on'] ******************************************************************************************* ['amount', 'of', 'po'] ******************************************************************************************* ['s', 'patient', 'is', 'taking'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['To', 'meet', '100', 'of', 'estimated', 'needs', 'recommend', 'Nutren', 'Pulmonary'] ******************************************************************************************* ['45mL', 'hr', '1620kcals', '73', 'g', 'protein'] ******************************************************************************************* ['Will', 'monitor', 'po', 'intake', 'and', 'mental', 'status', 'and', 'adjust', 'tube'] ******************************************************************************************* ['feeds', 'as', 'needed'] ******************************************************************************************* ['Following', 'g-', 'Numeric', 'Identifier', '1312'] ******************************************************************************************* [] ******************************************************************************************* ['40461,Nutrition,"Subjective'] ******************************************************************************************* ['intub'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Pertinent', 'medications', 'Multivitamins', 'FoLIC', 'Acid', 'Pantoprazole'] ******************************************************************************************* ['Potassium', 'Chloride', 'Norepinephrine', 'drip', 'others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['106', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['15', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['1.1', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['140', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.7', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['108', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['26', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['108', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '25', '03:53', 'AM'] ******************************************************************************************* ['PO2', 'venous'] ******************************************************************************************* ['48', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['53', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '25', '03:53', 'AM'] ******************************************************************************************* ['PCO2', 'venous'] ******************************************************************************************* ['33', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.32', 'units'] ******************************************************************************************* ['2113', '1', '25', '03:53', 'AM'] ******************************************************************************************* ['pH', 'venous'] ******************************************************************************************* ['7.43', 'units'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.0', 'units'] ******************************************************************************************* ['2113', '1', '25', '02:26', 'PM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['29', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '25', '03:53', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'venous'] ******************************************************************************************* ['23', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['2.1', 'g', 'dL'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['7.4', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['3.5', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['1.6', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['ALT'] ******************************************************************************************* ['27', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Alkaline', 'Phosphate'] ******************************************************************************************* ['50', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['AST'] ******************************************************************************************* ['27', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Amylase'] ******************************************************************************************* ['25', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Total', 'Bilirubin'] ******************************************************************************************* ['0.3', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '22', '05:17', 'AM'] ******************************************************************************************* ['Triglyceride'] ******************************************************************************************* ['120', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['11.4', 'K', 'uL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['9.6', 'g', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['30.3'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Nutren', 'Pulmonary', 'Full', 'strength'] ******************************************************************************************* ['Additives', 'Banana', 'flakes', '3', 'packets', 'per', 'day'] ******************************************************************************************* ['Starting', 'rate', '10', 'ml', 'hr', 'Advance', 'rate', 'by', '10', 'ml', 'q4h', 'Goal', 'rate', '45', 'ml', 'hr'] ******************************************************************************************* ['Residual', 'Check', 'q4h', 'Hold', 'feeding', 'for', 'residual', '>', '=', '200', 'ml'] ******************************************************************************************* ['Flush', 'w/', '100', 'ml', 'water', 'q8h', 'not', 'running', 'since', '8', 'am', 'this', 'morning'] ******************************************************************************************* ['NPO', 'for', 'Procedure', 'Start', 'After', '12:01AM', 'Procedure', 'CSURG', 'on', 'date'] ******************************************************************************************* ['2113', '1', '26'] ******************************************************************************************* ['Do', 'NOT', 'resume', 'diet', 'after', 'procedure'] ******************************************************************************************* ['GI', 'Abd', 'soft', 'ND', 'NT', 'NBS'] ******************************************************************************************* ['Ext', '2', '+', 'pulses', '2', '+', 'edema', 'in', 'lower', 'extremtiies', 'R', '>', 'L'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['49', 'year', 'old', 'male', 'found', 'to', 'have', 'staphlyococcus', 'aureus', 'bacterial'] ******************************************************************************************* ['endocarditis', 'with', 'severe', 'mitral', 'regurgitation', '3', '21', 'mitral', 'valve'] ******************************************************************************************* ['vegetations', 'and', 'flail', 'leaflet', 'patient', 'pending', 'OR', 'tomorrow', 'for', 'AVR', 'and'] ******************************************************************************************* ['MVR', 'with', 'debridement', 'of', 'the', 'epidural', 'abscess', 'Patient', 'received', 'minimal'] ******************************************************************************************* ['nutrition', 'since', 'admission', 'had', '<', '24hours', 'tube', 'feed', 'from', '12/7', '8)', 'at', 'very'] ******************************************************************************************* ['high', 'risk', 'for', 'malnutrition', 'recommend', 'closely', 'monitor', 'post', 'cardiac'] ******************************************************************************************* ['surgery', 'may', 'need', 'to', 'restart', 'tube', 'feed', 'as', 'patient', 'was', 'refusing', 'all', 'po'] ******************************************************************************************* ['food', 'this', 'admission'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['Multivitamin', 'Mineral', 'supplement', 'discontinue', 'outside', 'order'] ******************************************************************************************* ['if', 'tube', 'feed', 'restarts'] ******************************************************************************************* ['Tube', 'feeding', 'recommendations', 'restart', 'tube', 'feed', 'as', 'ordered'] ******************************************************************************************* ['Check', 'chemistry', '10', 'panel', 'daily', 'replete', 'as', 'you', 'are', 'doing'] ******************************************************************************************* ['Start', 'regular', 'insulin', 'sliding', 'scale', 'if', 'serum', 'glucose', 'greater'] ******************************************************************************************* ['than', '150', 'mg', 'dL'] ******************************************************************************************* ['Other', 'Numeric', 'Identifier', '943', 'if', 'has', 'question'] ******************************************************************************************* [] ******************************************************************************************* ['40461,Nutrition,"Ht', '70'] ******************************************************************************************* ['Wt', '57.8', 'kg'] ******************************************************************************************* ['IBW', '75.3', 'kg/', '77'] ******************************************************************************************* ['BMI', '18.2'] ******************************************************************************************* ['Pmh', 'Diabetes', 'Dyslipidemia', 'Hypertension', '1', '25', 'multiple', 'embolic', 'events'] ******************************************************************************************* ['worst', 'is', 'large', 'left', 'posterior', 'cerebral', 'artery', 'infarct(neurologic'] ******************************************************************************************* ['deficits', 'including', 'left', 'sided', 'facial', 'droop', 'right', 'sided', 'neglect', 'right'] ******************************************************************************************* ['sided', 'hemiparesis', 'expressive', 'aphasia'] ******************************************************************************************* ['MVR(29', 'mm', 'St.', 'Male', 'First', 'Name', 'un', '1104', 'Mechanical', 'Valve', 'with', 'Debridement', 'of', 'Aortic', 'Valve'] ******************************************************************************************* ['Teeth', 'extraction', '2113', '1', '23'] ******************************************************************************************* ['Diet', 'Order', 'regular'] ******************************************************************************************* ['49', 'year', 'old', 'male', 'was', 'in', 'rehab', 's', 'p', 'M.', 'Patient', 'admitted', 'to', 'outside'] ******************************************************************************************* ['hospital', 'CT', 'showed', 'depressed', 'fx', 'of', 'right', 'frontal', 'sinus', 'Patient'] ******************************************************************************************* ['transferred'] ******************************************************************************************* ['Potential', 'for', 'nutrition', 'risk', 'Patient', 'being', 'monitored', 'Current'] ******************************************************************************************* ['intervention', 'if', 'any', 'listed', 'below'] ******************************************************************************************* ['Comments'] ******************************************************************************************* [] ******************************************************************************************* ['40461,Nutrition,"Ht', '70'] ******************************************************************************************* ['Wt', '57.8', 'kg'] ******************************************************************************************* ['IBW', '75.3', 'kg/', '77'] ******************************************************************************************* ['BMI', '18.2'] ******************************************************************************************* ['Pmh', 'Diabetes', 'Dyslipidemia', 'Hypertension', '1', '25', 'multiple', 'embolic', 'events'] ******************************************************************************************* ['worst', 'is', 'large', 'left', 'posterior', 'cerebral', 'artery', 'infarct(neurologic'] ******************************************************************************************* ['deficits', 'including', 'left', 'sided', 'facial', 'droop', 'right', 'sided', 'neglect', 'right'] ******************************************************************************************* ['sided', 'hemiparesis', 'expressive', 'aphasia'] ******************************************************************************************* ['MVR(29', 'mm', 'St.', 'Male', 'First', 'Name', 'un', '1104', 'Mechanical', 'Valve', 'with', 'Debridement', 'of', 'Aortic', 'Valve'] ******************************************************************************************* ['Teeth', 'extraction', '2113', '1', '23'] ******************************************************************************************* ['Diet', 'Order', 'regular'] ******************************************************************************************* ['49', 'year', 'old', 'male', 'on', 'coumadin', 'for', 'a', 'prosthetic', 'mitral', 'valve', 'after'] ******************************************************************************************* ['having', 'Staphylococcal', 'endocarditis', 'of', 'MV', 'and', 'AV', 'c', 'b', 'multiple', 'embolic'] ******************************************************************************************* ['strokes', 'admitted', 'from', 'rehab', 's', 'p', 'fall', 'Patient', 'tolerating', 'diet', 'no', 'nausea'] ******************************************************************************************* ['or', 'vomiting', 'Patient', 'reports', 'much', 'better', 'po', 'intake', 'since', 'admit', 'to'] ******************************************************************************************* ['Hospital1', '5', 'Patient', 'unsure', 'of', 'wt', 'loss', 'PTA', 'and', 'unsure', 'of', 'usual', 'body', 'wt', 'Will'] ******************************************************************************************* ['add', 'supplements', 'to', 'increase', 'caloric', 'intake'] ******************************************************************************************* ['Recommendations'] ******************************************************************************************* ['1', 'Encourage', 'pos', 'and', 'supplements'] ******************************************************************************************* ['2', 'Will', 'add', 'ensure', 'TID'] ******************************************************************************************* ['3', 'Will', 'follow', 'page', 'Numeric', 'Identifier', '1372', 'with', 'questions'] ******************************************************************************************* [] ******************************************************************************************* ['40461,Nutrition,"Subjective'] ******************************************************************************************* ['oriented', 'x', '1'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['178', 'cm'] ******************************************************************************************* ['63', 'kg'] ******************************************************************************************* ['72', 'kg', '2113', '2', '1', '04:00', 'AM'] ******************************************************************************************* ['19.9'] ******************************************************************************************* ['Pertinent', 'medications', 'Ranitidine', 'ABX', 'Folic', 'Acid', 'Thiamine'] ******************************************************************************************* ['Multi', 'vitamin', 'lasix', 'Colace', 'Held', 'KCl', '20mEq', 'repletion', 'x3'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['108', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['124'] ******************************************************************************************* ['2113', '2', '1', '12:00', 'AM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['28', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['2.0', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['139', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.7', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['105', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['23', 'mEq', 'L'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['65', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['PO2', 'venous'] ******************************************************************************************* ['48', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['30', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['PCO2', 'venous'] ******************************************************************************************* ['33', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.46', 'units'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['pH', 'venous'] ******************************************************************************************* ['7.43', 'units'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.5', 'units'] ******************************************************************************************* ['2113', '2', '1', '07:16', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['22', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '31', '04:47', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'venous'] ******************************************************************************************* ['23', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['2.2', 'g', 'dL'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['7.6', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['4.6', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['Ionized', 'Calcium'] ******************************************************************************************* ['1.08', 'mmol', 'L'] ******************************************************************************************* ['2113', '1', '30', '11:46', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['2.2', 'mg', 'dL'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['ALT'] ******************************************************************************************* ['20', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Alkaline', 'Phosphate'] ******************************************************************************************* ['57', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['AST'] ******************************************************************************************* ['26', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Amylase'] ******************************************************************************************* ['17', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Total', 'Bilirubin'] ******************************************************************************************* ['0.4', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Triglyceride'] ******************************************************************************************* ['120', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['18.2', 'K', 'uL'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['10.4', 'g', 'dL'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['31.5'] ******************************************************************************************* ['2113', '2', '1', '03:30', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Diet', 'Ground', 'solids', 'thin'] ******************************************************************************************* ['liquids', 'Ensure', 'Pudding', 'and', 'Carnation', 'Instant', 'Breakfast', 'with', 'meals'] ******************************************************************************************* ['calorie', 'counts', '2', '1', '2', '2', '2', '3'] ******************************************************************************************* ['GI', 'soft', '+', 'bowel', 'sounds', 'green', 'liquid', 'stool'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['Estimation', 'of', 'current', 'intake', 'Inadequate'] ******************************************************************************************* ['Specifics'] ******************************************************************************************* ['Patient', 's', 'p', 'MVR', 'AVR', '1', '27', 'Extubated', '1', '30', 'Seen', 'by', 'SLP', '1', '31', 'who'] ******************************************************************************************* ['recommended', 'above', 'altered', 'consistency', 'diet', 'with', '1:1', 'supervision', 'Name8', 'MD'] ******************************************************************************************* ['RN', 'patient', 'took', 'Ensure', 'pudding', 'and', 'some', 'Carnation', 'Instant', 'Breakfast'] ******************************************************************************************* ['shake', 'this', 'AM', 'with', 'a', 'lot', 'of', 'encouragement', 'Patient', 'takes', 'very', 'small'] ******************************************************************************************* ['bites', 'and', 'is', 'a', 'picky', 'eater', 'RN', 'reports', 'wife', 'to', 'bring', 'in', 'a', 'list', 'of'] ******************************************************************************************* ['foods', 'that', 'patient', 'likes', 'Calorie', 'counts', 'starting', 'today', 'Concerned'] ******************************************************************************************* ['with', 'nutrition', 'status', 'given', 'poor', 'po'] ******************************************************************************************* ['s', 'during', 'admit', 'refusing', 'po'] ******************************************************************************************* ['s', 'at'] ******************************************************************************************* ['times', 'only', 'received', 'tube', 'feed', 'briefly', 'on', 'off', 'and', 'recent', 'surgery'] ******************************************************************************************* ['Would', 'strongly', 'recommend', 'supplemental', 'tube', 'feed', 'to', 'optimize', 'nutrition'] ******************************************************************************************* ['for', 'post', 'op', 'recovery'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['Current', 'diet', 'nutrition', 'support', 'is', 'appropriate'] ******************************************************************************************* ['Encourage', 'assist', 'with', 'po'] ******************************************************************************************* ['o', 'Encourage', 'wife', 'to', 'bring', 'in', 'food', 'preference', 'list', 'or', 'food'] ******************************************************************************************* ['o', 'Calorie', 'counts'] ******************************************************************************************* ['please', 'record', 'on', 'kitchen', 'receipt', 'percent'] ******************************************************************************************* ['eaten'] ******************************************************************************************* ['Oral', 'supplements', 'Continue', 'as', 'ordered'] ******************************************************************************************* ['Multivitamin', 'Mineral', 'supplement', 'continue', 'current'] ******************************************************************************************* ['Tube', 'feeding', 'recommendations'] ******************************************************************************************* ['o', 'Consider', 'placing', 'NGT', 'and', 'beginning', 'tube', 'feeds', 'to', 'supplement'] ******************************************************************************************* ['poor', 'po'] ******************************************************************************************* ['o', 'Tube', 'feed', 'goal', 'would', 'be', 'Nutren', 'Pulmonary', '45ml', 'hr', '=', '1620'] ******************************************************************************************* ['calories', 'and', '73', 'g', 'protein'] ******************************************************************************************* ['Check', 'chemistry', '10', 'panel', 'daily'] ******************************************************************************************* ['Will', 'follow', 'page', 'if', 'questions', 'Numeric', 'Identifier', '606'] ******************************************************************************************* [] ******************************************************************************************* ['40461,Nutrition,"Subjective'] ******************************************************************************************* ['just', 'extubated'] ******************************************************************************************* ['Objective'] ******************************************************************************************* ['Height'] ******************************************************************************************* ['Admit', 'weight'] ******************************************************************************************* ['Daily', 'weight'] ******************************************************************************************* ['Weight', 'change'] ******************************************************************************************* ['BMI'] ******************************************************************************************* ['178', 'cm'] ******************************************************************************************* ['63', 'kg'] ******************************************************************************************* ['76.2', 'kg', '2113', '1', '30', '04:00', 'AM'] ******************************************************************************************* ['19.9'] ******************************************************************************************* ['Pertinent', 'medications', 'Multivitamins', 'others', 'noted'] ******************************************************************************************* ['Labs'] ******************************************************************************************* ['Value'] ******************************************************************************************* ['Date'] ******************************************************************************************* ['Glucose'] ******************************************************************************************* ['106', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '30', '07:59', 'AM'] ******************************************************************************************* ['Glucose', 'Finger', 'Stick'] ******************************************************************************************* ['93'] ******************************************************************************************* ['2113', '1', '29', '06:00', 'PM'] ******************************************************************************************* ['BUN'] ******************************************************************************************* ['20', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Creatinine'] ******************************************************************************************* ['1.6', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Sodium'] ******************************************************************************************* ['137', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Potassium'] ******************************************************************************************* ['3.5', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Chloride'] ******************************************************************************************* ['104', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['TCO2'] ******************************************************************************************* ['22', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['PO2', 'arterial'] ******************************************************************************************* ['85.[**Numeric', 'Identifier', '299', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '30', '09:19', 'AM'] ******************************************************************************************* ['PO2', 'venous'] ******************************************************************************************* ['48', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['PCO2', 'arterial'] ******************************************************************************************* ['33', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '30', '09:19', 'AM'] ******************************************************************************************* ['PCO2', 'venous'] ******************************************************************************************* ['33', 'mm', 'Hg'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'arterial'] ******************************************************************************************* ['7.41', 'units'] ******************************************************************************************* ['2113', '1', '30', '09:19', 'AM'] ******************************************************************************************* ['pH', 'venous'] ******************************************************************************************* ['7.43', 'units'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['pH', 'urine'] ******************************************************************************************* ['5.0', 'units'] ******************************************************************************************* ['2113', '1', '25', '02:26', 'PM'] ******************************************************************************************* ['CO2', 'Calc', 'arterial'] ******************************************************************************************* ['22', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '30', '09:19', 'AM'] ******************************************************************************************* ['CO2', 'Calc', 'venous'] ******************************************************************************************* ['23', 'mEq', 'L'] ******************************************************************************************* ['2113', '1', '21', '05:21', 'PM'] ******************************************************************************************* ['Albumin'] ******************************************************************************************* ['2.2', 'g', 'dL'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Calcium', 'non', 'ionized'] ******************************************************************************************* ['8.4', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Phosphorus'] ******************************************************************************************* ['5.2', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Ionized', 'Calcium'] ******************************************************************************************* ['1.09', 'mmol', 'L'] ******************************************************************************************* ['2113', '1', '30', '07:59', 'AM'] ******************************************************************************************* ['Magnesium'] ******************************************************************************************* ['2.1', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['ALT'] ******************************************************************************************* ['20', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Alkaline', 'Phosphate'] ******************************************************************************************* ['57', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['AST'] ******************************************************************************************* ['26', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Amylase'] ******************************************************************************************* ['17', 'IU', 'L'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Total', 'Bilirubin'] ******************************************************************************************* ['0.4', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Triglyceride'] ******************************************************************************************* ['120', 'mg', 'dL'] ******************************************************************************************* ['2113', '1', '25', '03:36', 'AM'] ******************************************************************************************* ['WBC'] ******************************************************************************************* ['11.5', 'K', 'uL'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Hgb'] ******************************************************************************************* ['10.3', 'g', 'dL'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Hematocrit'] ******************************************************************************************* ['30.1'] ******************************************************************************************* ['2113', '1', '30', '03:25', 'AM'] ******************************************************************************************* ['Current', 'diet', 'order', 'nutrition', 'support', 'Nutren', 'Pulmonary', 'Full', 'strength'] ******************************************************************************************* ['Starting', 'rate', '10', 'ml', 'hr', 'Advance', 'rate', 'by', '10', 'ml', 'q4h', 'Goal', 'rate', '50', 'ml', 'hr'] ******************************************************************************************* ['Residual', 'Check', 'q4h', 'Hold', 'feeding', 'for', 'residual', '>', '=', '200', 'ml'] ******************************************************************************************* ['Flush', 'w/', '30', 'ml', 'water', 'q4h', 'not', 'running'] ******************************************************************************************* ['GI', 'soft', 'flesiseal', 'in', 'place'] ******************************************************************************************* ['SKIN', 'stage', '2', 'wounds'] ******************************************************************************************* ['Assessment', 'of', 'Nutritional', 'Status'] ******************************************************************************************* ['49', 'year', 'old', 'male', 'admitted', 'on', '1', '15', 'with', 'endocarditis', 's', 'p', 'MVR', 'and', 'aortic'] ******************************************************************************************* ['valve', 'debridement', 'on', '1', '27', 'patient', 'extubated', 'this', 'morning', 'Patient'] ******************************************************************************************* ['well', 'known', 'to', 'me', 'from', 'CCU', 'patient', 'with', 'minimal', 'nutrition', 'since'] ******************************************************************************************* ['hospital', 'admission', 'previously', 'refused', 'po', 'food', 'and', 'nutrition'] ******************************************************************************************* ['supplements', 'in', 'the', 'ccu', 'received', '1', 'day', 'of', 'tube', 'feed', 'prior', 'to', 'OR'] ******************************************************************************************* ['Patient', 'at', 'very', 'high', 'risk', 'for', 'malnutrition', 'highly', 'recommend', 'replace'] ******************************************************************************************* ['feeding', 'tube', 'restart', 'tube', 'feed', 'as', 'temporary', 'nutrition', 'support', 'for', 'post'] ******************************************************************************************* ['op', 'recovery'] ******************************************************************************************* ['Medical', 'Nutrition', 'Therapy', 'Plan', 'Recommend', 'the', 'Following'] ******************************************************************************************* ['Adv', 'diet', 'if', 'remains', 'medically', 'stable'] ******************************************************************************************* ['Continue', 'tube', 'feed', 'as', 'supplemental', 'nutrition', 'support', 'goal'] ******************************************************************************************* ['Nutren', 'Pulmonary', 'goal', '45ml', 'hr', 'to', 'provide', '1620kcal/73.4', 'g', 'protein'] ******************************************************************************************* ['Phos', 'binder', 'if', 'serum', 'phos', 'remains', 'elevated'] ******************************************************************************************* ['Check', 'chemistry', '10', 'panel', 'daily', 'replete', 'prn'] ******************************************************************************************* ['BS', 'management'] ******************************************************************************************* ['Other', 'Numeric', 'Identifier', '943'] ******************************************************************************************* [] *******************************************************************************************
In [25]:
df=notes
In [26]:
# Build corpus of all the entities extracted from the notes using spaCy model.
# The corpus is an array of arrays or list of lists where each of the nested lists corresponds to a note.
corpus=[]
for row in range(0, len(df)):
str_tokens=[]
tokens= nlp(df[row]).ents
for i in range(0, len(tokens)):
str_tokens.append(tokens[i].text)
corpus.append(list(str_tokens))
print(corpus)
[['SUBJECT_ID', 'CATEGORY', 'TEXT\n'], ['17610,Nutrition,"Patient', 'MICU', 'Diet'], ['NPO', 'NGT'], [], ['Identifier 5307'], [], ['40493,Nutrition,"Objective'], ['SS'], [], [], [], [], [], [], ['2172-11-9', '01:50 AM\n'], ['Stick'], ['120'], ['2172-11-9'], ['BUN'], [], ['2172-11-9', '01:50 AM\n'], [], [], ['2172-11-9', '01:50 AM\n'], [], ['137 mEq'], ['2172-11-9', '01:50 AM\n'], [], ['3.9 mEq'], ['2172-11-9', '01:50 AM\n'], [], [], ['2172-11-9', '01:50 AM\n'], [], [], ['2172-11-9', '01:50 AM\n'], ['PO2'], ['66 mm'], ['2172-11-9'], [], ['41 mm'], ['2172-11-9'], [], ['7.42'], ['2172-11-9'], [], ['5.0'], ['2172-11-1', '06:06 PM'], ['Calc'], [], ['2172-11-9'], [], [], ['2172-11-3', '02:24 AM'], [], [], ['2172-11-9', '01:50 AM\n'], [], [], ['2172-11-9', '01:50 AM\n'], ['Ionized Calcium\n'], ['1.11'], ['2172-11-5', '01:34 PM'], [], ['2.2'], ['2172-11-9', '01:50 AM\n'], ['1728'], [], ['Abd soft/+bs\n'], [], [], ['earlier today', 'TF'], [], ['100%'], [], [], [], ['SLP-', 'NGT', 'TF'], [], ['Identifier 1684'], [], [], [], [], [], [], [], [], ['BMI'], ['168 cm'], ['65 kg'], ['23.1'], [], [], [], [], [], ['64.4 kg'], ['101%'], [], ['PMH'], ['NKFA'], ['LR @ 10', 'IV'], [], [], [], [], [], ['155'], ['2172-11-2', '12:18 PM'], ['Stick'], ['151'], ['2172-11-2', '08:00 AM'], ['BUN'], [], ['2172-11-2', '12:18 PM'], [], ['0.8'], ['2172-11-2', '12:18 PM'], [], ['146 mEq'], ['2172-11-2', '12:18 PM'], [], ['3.6 mEq'], ['2172-11-2', '12:18 PM'], [], ['111 mEq'], ['2172-11-2', '12:18 PM'], [], [], ['2172-11-2', '12:18 PM'], ['PO2'], ['113 mm'], ['2172-11-2', '11:55 AM'], [], ['41 mm'], ['2172-11-2', '11:55 AM'], [], ['7.46'], ['2172-11-2', '11:55 AM'], [], ['5.0'], ['2172-11-1', '06:06 PM'], ['Calc'], [], ['2172-11-2', '11:55 AM'], [], ['3.0'], ['2172-10-31', '02:55 AM'], [], ['8.1'], ['2172-11-2', '12:18 PM'], [], [], ['2172-11-2', '12:18 PM'], ['Ionized Calcium\n'], ['1.16'], ['2172-11-2', '11:55 AM'], [], ['1.7'], ['2172-11-2', '12:18 PM'], [], [], ['2172-10-31', '02:55 AM'], ['Alkaline Phosphate'], ['IU/L'], ['2172-10-31', '02:55 AM'], [], [], ['2172-10-31', '02:55 AM'], ['Total Bilirubin'], [], ['2172-10-31', '02:55 AM'], ['WBC'], [], ['2172-11-2', '01:06 AM'], [], ['9.1'], ['2172-11-2', '01:06 AM'], ['Hematocrit'], ['27.2 %'], ['2172-11-2', '01:06 AM'], ['60'], [], ['GI'], [], [], ['NPO'], [], ['1625-[**2114', '25-30'], ['78-91', '1.2-1.4'], [], ['Likely Adequate'], [], ['57 year old', 'OSH'], ['CT'], ['MD', 'TF', '1440'], [], [], ['10', 'daily'], ['65ml', '1872'], [], ['3', 'Identifier 2584'], [], [], [], [], [], [], [], [], ['BMI'], ['168 cm'], ['65 kg'], ['23.1'], [], [], [], [], [], ['64.4 kg'], ['101%'], [], ['PMH'], ['NKFA'], ['LR @ 10', 'IV'], [], [], [], [], [], ['155'], ['2172-11-2', '12:18 PM'], ['Stick'], ['151'], ['2172-11-2', '08:00 AM'], ['BUN'], [], ['2172-11-2', '12:18 PM'], [], ['0.8'], ['2172-11-2', '12:18 PM'], [], ['146 mEq'], ['2172-11-2', '12:18 PM'], [], ['3.6 mEq'], ['2172-11-2', '12:18 PM'], [], ['111 mEq'], ['2172-11-2', '12:18 PM'], [], [], ['2172-11-2', '12:18 PM'], ['PO2'], ['113 mm'], ['2172-11-2', '11:55 AM'], [], ['41 mm'], ['2172-11-2', '11:55 AM'], [], ['7.46'], ['2172-11-2', '11:55 AM'], [], ['5.0'], ['2172-11-1', '06:06 PM'], ['Calc'], [], ['2172-11-2', '11:55 AM'], [], ['3.0'], ['2172-10-31', '02:55 AM'], [], ['8.1'], ['2172-11-2', '12:18 PM'], [], [], ['2172-11-2', '12:18 PM'], ['Ionized Calcium\n'], ['1.16'], ['2172-11-2', '11:55 AM'], [], ['1.7'], ['2172-11-2', '12:18 PM'], [], [], ['2172-10-31', '02:55 AM'], ['Alkaline Phosphate'], ['IU/L'], ['2172-10-31', '02:55 AM'], [], [], ['2172-10-31', '02:55 AM'], ['Total Bilirubin'], [], ['2172-10-31', '02:55 AM'], ['WBC'], [], ['2172-11-2', '01:06 AM'], [], ['9.1'], ['2172-11-2', '01:06 AM'], ['Hematocrit'], ['27.2 %'], ['2172-11-2', '01:06 AM'], ['60'], [], ['GI'], [], [], ['NPO'], [], ['1625-[**2114', '25-30'], ['78-91', '1.2-1.4'], [], ['Likely Adequate'], [], ['57 year old', 'OSH'], ['CT'], ['MD', 'TF', '1440'], [], [], ['10', 'daily'], ['65ml', '1872'], [], ['3', 'Identifier 2584'], [], ['61565,Nutrition,"Objective'], [], [], [], [], ['BMI'], ['178 cm'], ['88.2 kg'], ['27.8'], [], [], [], [], [], ['75.3 kg'], ['117%'], [], ['PMH'], [], ['Esmolol', 'dilantin'], [], [], [], [], [], [], ['2100-11-1', '02:37 AM\n'], ['Stick'], ['155'], ['2100-11-1*', '02:00 AM'], ['BUN'], [], ['2100-11-1', '02:37 AM\n'], [], ['0.8'], ['2100-11-1', '02:37 AM\n'], [], ['142 mEq'], ['2100-11-1', '02:37 AM\n'], [], [], ['2100-11-1', '02:37 AM\n'], [], ['111 mEq'], ['2100-11-1', '02:37 AM\n'], [], ['26 mEq'], ['2100-11-1', '02:37 AM\n'], ['PO2'], ['109 mm'], ['2100-11-1', '04:35 AM\n'], [], ['38 mm'], ['2100-11-1', '04:35 AM\n'], [], ['7.48'], ['2100-11-1', '04:35 AM\n'], ['Calc'], [], ['2100-11-1', '04:35 AM\n'], [], ['3.8'], ['2100-10-30'], [], ['8.9'], ['2100-11-1', '02:37 AM\n'], [], [], ['2100-11-1', '02:37 AM\n'], ['Ionized Calcium\n'], ['1.22'], ['2100-10-31'], [], [], ['2100-11-1', '02:37 AM\n'], ['Phenytoin', 'Dilantin'], [], ['2100-10-31', '02:34 AM'], ['WBC'], ['12.1'], ['2100-11-1', '02:37 AM\n'], [], ['11.9'], ['2100-11-1', '02:37 AM\n'], ['Hematocrit'], ['33.9 %'], ['2100-11-1', '02:37 AM\n'], [], ['Goal', '65 ml'], ['200 ml\n'], ['GI'], [], [], ['NPO'], [], ['2027**]-2200', 'BEE', '22-25 cal/kg'], ['114', '1.3 g/kg'], [], [], [], [], [], [], ['TF', 'yesterday'], [], ['TF'], [], [], ['10', 'daily'], ['Cont Bg'], ['Identifier 1550'], [], ['61565,Nutrition,"Objective'], [], [], [], [], ['BMI'], ['178 cm'], ['88.2 kg'], ['27.8'], [], [], [], [], [], ['75.3 kg'], ['117%'], [], ['PMH'], [], ['Esmolol', 'dilantin'], [], [], [], [], [], [], ['2100-11-1', '02:37 AM\n'], ['Stick'], ['155'], ['2100-11-1*', '02:00 AM'], ['BUN'], [], ['2100-11-1', '02:37 AM\n'], [], ['0.8'], ['2100-11-1', '02:37 AM\n'], [], ['142 mEq'], ['2100-11-1', '02:37 AM\n'], [], [], ['2100-11-1', '02:37 AM\n'], [], ['111 mEq'], ['2100-11-1', '02:37 AM\n'], [], ['26 mEq'], ['2100-11-1', '02:37 AM\n'], ['PO2'], ['109 mm'], ['2100-11-1', '04:35 AM\n'], [], ['38 mm'], ['2100-11-1', '04:35 AM\n'], [], ['7.48'], ['2100-11-1', '04:35 AM\n'], ['Calc'], [], ['2100-11-1', '04:35 AM\n'], [], ['3.8'], ['2100-10-30'], [], ['8.9'], ['2100-11-1', '02:37 AM\n'], [], [], ['2100-11-1', '02:37 AM\n'], ['Ionized Calcium\n'], ['1.22'], ['2100-10-31'], [], [], ['2100-11-1', '02:37 AM\n'], ['Phenytoin', 'Dilantin'], [], ['2100-10-31', '02:34 AM'], ['WBC'], ['12.1'], ['2100-11-1', '02:37 AM\n'], [], ['11.9'], ['2100-11-1', '02:37 AM\n'], ['Hematocrit'], ['33.9 %'], ['2100-11-1', '02:37 AM\n'], [], ['Goal', '65 ml'], ['200 ml\n'], [], [], [], [], [], ['1760-2200', 'BEE', '20-25 cal/kg'], ['114', '1.3 g/kg'], [], [], [], [], [], [], ['TF', 'yesterday'], ['1080', 'First'], ['TF'], [], ['Replete with Fiber'], ['1800kcal/112'], ['10', 'daily'], ['Cont Bg'], ['Identifier 1550'], [], ['61565,Nutrition,"Objective'], ['Heparin', 'Abx'], [], [], [], [], [], ['128'], ['2100-11-5', '03:32 AM'], ['Stick'], ['140'], ['2100-11-4', '08:00 PM'], ['BUN'], [], ['2100-11-5', '03:32 AM'], [], ['0.7'], ['2100-11-5', '03:32 AM'], [], [], ['2100-11-5', '03:32 AM'], [], ['3.9 mEq'], ['2100-11-5', '03:32 AM'], [], [], ['2100-11-5', '03:32 AM'], [], [], ['2100-11-5', '03:32 AM'], ['PO2'], [], ['2100-11-5', '07:26 AM'], [], ['37 mm'], ['2100-11-5', '07:26 AM'], [], ['7.49'], ['2100-11-5', '07:26 AM'], [], ['7.0'], ['2100-11-5', '11:05 AM'], ['Calc'], [], ['2100-11-5', '07:26 AM'], [], [], ['2100-11-4', '02:31 AM'], [], [], ['2100-11-4', '02:31 AM'], [], [], ['2100-11-4', '02:31 AM'], ['WBC'], [], ['2100-11-5', '03:32 AM'], [], ['12.0'], ['2100-11-5', '03:32 AM'], ['Hematocrit'], ['33.8 %'], ['2100-11-5', '03:32 AM'], ['Replete c/ Fiber @65mL', '1560'], [], [], [], [], [], ['IVC', 'yesterday', 'TF'], [], ['88%', '85%'], ['TF'], [], [], [], ['TF'], ['75 mL', '1800'], [], ['BG'], ['Identifier 1684'], [], ['NPO', '1'], [], ['1511'], [], [], [], ['4-17', 'O2', 'PACU'], [], [], ['24-48hrs'], [], [], ['Identifier 1687'], [], [], ['58054,Nutrition,"Comments'], [], [], ['Identifier 2337'], [], ['99573,Nutrition,"Subjective'], [], ['PTA', 'XRT'], [], [], [], [], [], ['BMI'], ['168 cm'], ['98.2 kg'], ['34.9'], [], [], [], [], [], ['59 kg'], ['166%'], ['68.8 kg'], [], ['PMH', 'polymyalgia', 'NIDDM'], [], [], ['IV', '30 mEq', 'Dextrose'], ['5%'], [], [], [], [], [], ['2181-6-5', '08:00 AM'], ['Stick'], ['222'], ['2181-6-4', '08:00 PM'], ['BUN'], [], ['2181-6-4', '11:36 PM'], [], [], ['2181-6-4', '11:36 PM'], [], [], ['2181-6-4', '11:36 PM'], [], [], ['2181-6-5', '09:13 AM'], [], [], ['2181-6-4', '11:36 PM'], [], ['26 mEq'], ['2181-6-4', '11:36 PM'], [], ['6.5'], ['2181-6-3', '12:30 AM'], [], ['8.5'], ['2181-6-4', '11:36 PM'], [], [], ['2181-6-4', '11:36 PM'], [], ['2.0'], ['2181-6-4', '11:36 PM'], ['WBC'], [], ['2181-6-5', '12:03 AM'], [], ['10.9'], ['2181-6-5', '12:03 AM'], ['Hematocrit'], ['32.7 %'], ['2181-6-5', '12:03 AM'], [], ['GI', 'obese'], [], ['Obese'], ['NPO'], [], ['1513-1720', '22-25 cal/kg'], ['83', '1.2-1.5'], [], [], ['NPO'], ['78 year old', 'S/P'], ['Le Forte'], ['fx', 'fx', '6'], ['NPO'], [], [], [], [], [], ['15 ml', '65 ml', '1560'], [], ['4-6 hours', 'greater than 150'], [], ['IV'], [], ['Identifier 1372'], [], ['40461,Nutrition,"Subjective'], [], [], [], [], [], [], ['BMI'], ['178 cm'], ['63 kg'], ['2113-2-3', '04:00 AM'], [], ['Ranitidine', 'Multi', 'ABX', 'Folic Acid'], ['Thiamine', 'Coumadin', 'Lasix', 'Colace', '20mEq'], ['2', 'Heparin'], [], [], [], [], ['105'], ['2113-2-3', '05:24 AM'], ['Stick'], ['127'], ['2113-2-3', '12:00 PM'], ['BUN'], [], ['2113-2-3', '05:24 AM'], [], [], ['2113-2-3', '05:24 AM'], [], ['142 mEq'], ['2113-2-3', '05:24 AM'], [], ['3.9 mEq'], ['2113-2-3', '05:24 AM'], [], [], ['2113-2-3', '05:24 AM'], [], [], ['2113-2-3', '05:24 AM'], ['PO2'], ['65 mm'], ['2113-1-31', '04:47 AM\n'], ['PO2'], ['48 mm'], ['2113-1-21', '05:21 PM'], [], ['30 mm'], ['2113-1-31', '04:47 AM\n'], [], ['33 mm'], ['2113-1-21', '05:21 PM'], [], ['7.46'], ['2113-1-31', '04:47 AM\n'], [], ['7.43'], ['2113-1-21', '05:21 PM'], [], ['5.5'], ['2113-2-1', '07:16 AM\n'], ['Calc'], [], ['2113-1-31', '04:47 AM\n'], ['Calc'], [], ['2113-1-21', '05:21 PM'], [], ['2.1'], ['2113-2-1', '02:44 PM'], [], ['7.5'], ['2113-2-3', '05:24 AM'], [], [], ['2113-2-3', '05:24 AM'], ['Ionized Calcium\n'], ['1.08'], ['2113-1-30', '11:46 AM'], [], [], ['2113-2-3', '05:24 AM'], [], [], ['2113-2-3', '05:24 AM'], ['Alkaline Phosphate'], [], ['2113-2-3', '05:24 AM'], [], ['IU/L\n'], ['2113-2-3', '05:24 AM'], [], ['IU/L\n'], ['2113-2-3', '05:24 AM'], ['Total Bilirubin'], ['0.3'], ['2113-2-3', '05:24 AM'], [], [], ['2113-1-25'], ['WBC'], ['9.3'], ['2113-2-3', '05:24 AM'], [], ['8.9'], ['2113-2-3', '05:24 AM'], ['Hematocrit'], ['27.0 %'], ['2113-2-3', '05:24 AM'], [], ['2', '17 - 18'], ['GI', 'today'], [], [], [], ['49 year old', 's/p MVR'], ['29mm', 'First', 'First Name4', '1104', '1105', '1-27'], [], ['thin liquid\n'], [], [], ['880', '2'], ['270', '2'], ['NPO'], ['PEG'], ['NGT'], [], [], [], [], [], ['NPO'], [], ['PEG'], ['Isosource 1.5'], ['45ml', '1620'], [], [], [], ['10', 'daily'], ['PRN'], ['606'], [], ['40461,Nutrition,"Subjective'], ['40 ml'], [], [], [], [], [], [], [], ['2113-2-8', '08:00 AM'], ['Stick'], [], ['2113-2-7', '10:00 PM'], ['BUN'], [], ['2113-2-8', '02:50 AM'], [], ['2.0'], ['2113-2-8', '02:50 AM'], [], [], ['2113-2-8', '02:50 AM'], [], [], ['2113-2-8', '07:52 AM'], [], [], ['2113-2-8', '02:50 AM'], [], [], ['2113-2-8', '02:50 AM'], ['PO2'], ['65 mm'], ['2113-1-31', '04:47 AM\n'], ['PO2'], ['48 mm'], ['2113-1-21', '05:21 PM'], [], ['30 mm'], ['2113-1-31', '04:47 AM\n'], [], ['33 mm'], ['2113-1-21', '05:21 PM'], [], ['7.46'], ['2113-1-31', '04:47 AM\n'], [], ['7.43'], ['2113-2-7', '05:19 PM'], [], ['5.5'], ['2113-2-1', '07:16 AM\n'], ['Calc'], [], ['2113-1-31', '04:47 AM\n'], ['Calc'], [], ['2113-1-21', '05:21 PM'], [], ['2.2'], ['2113-2-6', '04:05 AM\n'], [], ['7.8'], ['2113-2-6', '04:05 AM\n'], [], [], ['2113-2-6', '04:05 AM\n'], ['Ionized Calcium\n'], ['1.07'], ['2113-2-7', '05:19 PM'], [], ['2.1'], ['2113-2-8', '07:52 AM'], [], ['IU/L\n'], ['2113-2-6', '04:05 AM\n'], ['Alkaline Phosphate'], [], ['2113-2-6', '04:05 AM\n'], [], [], ['2113-2-6', '04:05 AM\n'], [], ['IU/L\n'], ['2113-2-6', '04:05 AM\n'], ['Total Bilirubin'], ['0.4'], ['2113-2-6', '04:05 AM\n'], [], [], ['2113-1-25'], ['WBC'], ['10.1'], ['2113-2-8', '02:50 AM'], [], ['8.3'], ['2113-2-8', '02:50 AM'], ['Hematocrit'], ['26.1 %'], ['2113-2-8', '02:50 AM'], [], [], ['40 ml', 'Advance', '20 ml', '70 ml'], ['200 ml\n'], ['30 ml water q8h\n'], ['Bowel'], [], [], ['49 year old', 's/p PEG', 'yesterday'], ['yesterday', 'Isosource 1.5'], ['this morning'], ['Fibersource'], [], [], [], ['1728kcal/76'], [], ['10'], [], [], [], ['40461,Nutrition,"Subjective'], [], [], [], [], [], [], ['BMI'], ['178 cm'], ['63 kg'], ['70.8 kg', '2113-2-7', '04:00 AM'], [], ['Multiple Vitamins'], [], [], [], [], [], ['157'], ['2113-2-7', '04:00 AM\n'], ['Stick'], ['158'], ['2113-2-7', '06:00 AM'], ['BUN'], [], ['2113-2-7', '04:00 AM\n'], [], [], ['2113-2-7', '04:00 AM\n'], [], ['145 mEq'], ['2113-2-7', '04:00 AM\n'], [], [], ['2113-2-7', '04:00 AM\n'], [], ['111 mEq'], ['2113-2-7', '04:00 AM\n'], [], [], ['2113-2-7', '04:00 AM\n'], ['PO2'], ['65 mm'], ['2113-1-31', '04:47 AM\n'], ['PO2'], ['48 mm'], ['2113-1-21', '05:21 PM'], [], ['30 mm'], ['2113-1-31', '04:47 AM\n'], [], ['33 mm'], ['2113-1-21', '05:21 PM'], [], ['7.46'], ['2113-1-31', '04:47 AM\n'], [], ['7.43'], ['2113-1-21', '05:21 PM'], [], ['5.5'], ['2113-2-1', '07:16 AM\n'], ['Calc'], [], ['2113-1-31', '04:47 AM\n'], ['Calc'], [], ['2113-1-21', '05:21 PM'], [], ['2.2'], ['2113-2-6', '04:05 AM\n'], [], ['7.8'], ['2113-2-6', '04:05 AM\n'], [], [], ['2113-2-6', '04:05 AM\n'], ['Ionized Calcium\n'], ['1.08'], ['2113-1-30', '11:46 AM'], [], ['2.0'], ['2113-2-6', '11:00 PM'], [], ['IU/L\n'], ['2113-2-6', '04:05 AM\n'], ['Alkaline Phosphate'], [], ['2113-2-6', '04:05 AM\n'], [], [], ['2113-2-6', '04:05 AM\n'], [], ['IU/L\n'], ['2113-2-6', '04:05 AM\n'], ['Total Bilirubin'], ['0.4'], ['2113-2-6', '04:05 AM\n'], [], [], ['2113-1-25'], ['WBC'], [], ['2113-2-7', '04:00 AM\n'], [], ['8.8'], ['2113-2-7', '04:00 AM\n'], ['Hematocrit'], ['26.9 %'], ['2113-2-7', '04:00 AM\n'], [], ['2113-2-6', '270drextrose/80protein/35fat'], [], ['10 ml', 'Advance', '10 ml q6h Goal', '60 ml'], ['200 ml\n'], ['30 ml water q8h\n'], ['Bowel'], ['Peg'], [], ['49 year old', 'Mitral', 's/p MVR'], ['1-27', 'S & S'], ['TPN', 'the weekend', 'PEG', 'PEG'], ['yesterday', 'today'], [], [], [], [], ['1 TPN', 'tonight'], [], ['Isosource 1.5cal', '1620kcal/73'], [], ['15ml'], ['10'], [], [], [], ['40461,Nutrition,"Subjective'], [], [], [], [], [], [], ['BMI'], ['178 cm'], ['63 kg'], ['2113-2-3', '04:00 AM'], [], ['D5', '40 mEq', 'IV'], [], [], [], [], [], [], ['2113-2-4', '12:00 PM'], ['Stick'], ['135'], ['2113-2-4', '12:00 AM'], ['BUN'], [], ['2113-2-4', '03:42 AM\n'], [], [], ['2113-2-4', '03:42 AM\n'], [], [], ['2113-2-4', '03:42 AM\n'], [], [], ['2113-2-4', '03:42 AM\n'], [], ['108 mEq'], ['2113-2-4', '03:42 AM\n'], [], [], ['2113-2-4', '03:42 AM\n'], ['PO2'], ['65 mm'], ['2113-1-31', '04:47 AM\n'], ['PO2'], ['48 mm'], ['2113-1-21', '05:21 PM'], [], ['30 mm'], ['2113-1-31', '04:47 AM\n'], [], ['33 mm'], ['2113-1-21', '05:21 PM'], [], ['7.46'], ['2113-1-31', '04:47 AM\n'], [], ['7.43'], ['2113-1-21', '05:21 PM'], [], ['5.5'], ['2113-2-1', '07:16 AM\n'], ['Calc'], [], ['2113-1-31', '04:47 AM\n'], ['Calc'], [], ['2113-1-21', '05:21 PM'], [], ['2.1'], ['2113-2-1', '02:44 PM'], [], ['7.3'], ['2113-2-4', '03:42 AM\n'], [], ['3.1'], ['2113-2-4', '03:42 AM\n'], ['Ionized Calcium\n'], ['1.08'], ['2113-1-30', '11:46 AM'], [], ['2.0'], ['2113-2-4', '03:42 AM\n'], [], [], ['2113-2-3', '05:24 AM'], ['Alkaline Phosphate'], [], ['2113-2-3', '05:24 AM'], [], ['IU/L\n'], ['2113-2-3', '05:24 AM'], [], ['IU/L\n'], ['2113-2-3', '05:24 AM'], ['Total Bilirubin'], ['0.3'], ['2113-2-3', '05:24 AM'], [], [], ['2113-1-25'], ['WBC'], [], ['2113-2-4', '03:42 AM\n'], [], ['9.8'], ['2113-2-4', '03:42 AM\n'], ['Hematocrit'], ['29.7 %'], ['2113-2-4', '03:42 AM\n'], [], ['GI'], [], ['2'], ['NPO', 'PPN', 'PA'], ['PEG', 'Monday'], ['PEG'], ['tonight', 'NGT'], [], [], [], ['TPN', '270'], ['1588'], ['3', '400'], ['Isosource HN @', '15 ml'], ['45 ml', '1620', '73'], ['Identifier 1372'], [], ['40461,Nutrition,"Subjective'], ['MD'], [], [], [], [], [], ['BMI'], ['178 cm'], ['63 kg'], ['70.5 kg', '2113-1-19', '08:00 AM'], [], [], [], [], [], [], [], ['75.3 kg'], ['119%'], ['63 kg'], [], [], ['30 years'], [], ['Thiamine'], ['Nicotine Patch', 'Nafcillin'], [], [], [], [], [], [], ['2113-1-20'], ['BUN'], [], ['2113-1-20'], [], [], ['2113-1-20'], [], ['137 mEq'], ['2113-1-20'], [], [], ['2113-1-20'], [], [], ['2113-1-20'], [], [], ['2113-1-20'], ['PO2'], ['145 mm'], ['2113-1-15', '04:51 PM\n'], [], ['34 mm'], ['2113-1-15', '04:51 PM\n'], [], ['7.45'], ['2113-1-15', '04:51 PM\n'], [], ['5.0'], ['2113-1-18', '12:03 PM'], ['Calc'], [], ['2113-1-15', '04:51 PM\n'], [], ['1.9'], ['2113-1-18', '07:15 AM\n'], [], [], ['2113-1-20'], [], [], ['2113-1-20'], [], [], ['2113-1-20'], [], [], ['2113-1-20'], ['Alkaline Phosphate'], [], ['2113-1-20'], [], ['IU/L'], ['2113-1-20'], ['Total Bilirubin'], ['0.4'], ['2113-1-20'], ['WBC'], [], ['2113-1-20'], [], ['11.8'], ['2113-1-20'], ['Hematocrit'], ['35.2 %'], ['2113-1-20'], [], [], ['Bowel'], [], [], [], [], [], ['CT'], [], [], [], ['1575-1764', 'BEE'], ['76-88', '1.2-1.4'], [], [], [], [], [], ['49 year old'], ['3'], ['5', 'CT'], [], ['this morning'], ['NGT'], [], [], ['Nutren Pulmonary', '45ml'], ['1620kcal/73.4'], [], ['10'], [], [], [], [], [], ['40461,Nutrition,"Subjective'], ['MD'], [], [], [], [], [], ['BMI'], ['178 cm'], ['63 kg'], ['70.5 kg', '2113-1-19', '08:00 AM'], [], [], [], [], [], [], [], ['75.3 kg'], ['119%'], ['63 kg'], [], [], ['30 years'], [], ['Thiamine'], ['Nicotine Patch', 'Nafcillin'], [], [], [], [], [], [], ['2113-1-20'], ['BUN'], [], ['2113-1-20'], [], [], ['2113-1-20'], [], ['137 mEq'], ['2113-1-20'], [], [], ['2113-1-20'], [], [], ['2113-1-20'], [], [], ['2113-1-20'], ['PO2'], ['145 mm'], ['2113-1-15', '04:51 PM\n'], [], ['34 mm'], ['2113-1-15', '04:51 PM\n'], [], ['7.45'], ['2113-1-15', '04:51 PM\n'], [], ['5.0'], ['2113-1-18', '12:03 PM'], ['Calc'], [], ['2113-1-15', '04:51 PM\n'], [], ['1.9'], ['2113-1-18', '07:15 AM\n'], [], [], ['2113-1-20'], [], [], ['2113-1-20'], [], [], ['2113-1-20'], [], [], ['2113-1-20'], ['Alkaline Phosphate'], [], ['2113-1-20'], [], ['IU/L'], ['2113-1-20'], ['Total Bilirubin'], ['0.4'], ['2113-1-20'], ['WBC'], [], ['2113-1-20'], [], ['11.8'], ['2113-1-20'], ['Hematocrit'], ['35.2 %'], ['2113-1-20'], [], [], ['Bowel'], [], [], [], [], [], ['CT'], [], [], [], ['1575-1764', 'BEE'], ['76-88', '1.2-1.4'], [], [], [], [], [], ['49 year old'], ['3'], ['5', 'CT'], [], ['this morning'], ['NGT'], [], [], ['Nutren Pulmonary', '45ml'], ['1620kcal/73.4'], [], ['10'], [], [], [], [], [], ['Physician Note'], ['this day'], [], [], [], [], [], [], ['ARF'], ['Createnine', 'today', '1.5'], ['NI', '1880', 'last night'], ['WBC', '13', '14', 'yesterday', 'Nafcillin'], [], [], ['91'], [], ['MD'], ['05:48 PM'], [], ['40461,Nutrition,"Subjective'], [], [], [], [], [], ['BMI'], ['178 cm'], ['63 kg'], ['72 kg', '2113-1-22', '10:00 AM'], [], [], [], [], [], [], [], ['2113-1-22', '05:17 AM\n'], ['BUN'], [], ['2113-1-22', '05:17 AM\n'], [], [], ['2113-1-22', '05:17 AM\n'], [], ['137 mEq'], ['2113-1-22', '05:17 AM\n'], [], ['4.3 mEq'], ['2113-1-22', '05:17 AM\n'], [], [], ['2113-1-22', '05:17 AM\n'], [], [], ['2113-1-22', '05:17 AM\n'], ['PO2'], ['61 mm'], ['2113-1-22', '12:22 AM'], ['PO2'], ['48 mm'], ['2113-1-21', '05:21 PM'], [], ['31 mm'], ['2113-1-22', '12:22 AM'], [], ['33 mm'], ['2113-1-21', '05:21 PM'], [], ['7.37'], ['2113-1-22', '12:22 AM'], [], ['7.43'], ['2113-1-21', '05:21 PM'], [], ['5.0'], ['2113-1-20', '06:24 PM'], ['Calc'], [], ['2113-1-22', '12:22 AM'], ['Calc'], [], ['2113-1-21', '05:21 PM'], [], ['2.1'], ['2113-1-22', '05:17 AM\n'], [], [], ['2113-1-22', '05:17 AM\n'], [], ['3.8'], ['2113-1-22', '05:17 AM\n'], [], ['2.0'], ['2113-1-22', '05:17 AM\n'], [], [], ['2113-1-22', '05:17 AM\n'], ['Alkaline Phosphate'], [], ['2113-1-22', '05:17 AM\n'], [], [], ['2113-1-22', '05:17 AM\n'], ['Total Bilirubin'], ['0.3'], ['2113-1-22', '05:17 AM\n'], ['WBC'], ['20.7'], ['2113-1-22', '05:17 AM\n'], [], ['12.9'], ['2113-1-22', '05:17 AM\n'], ['Hematocrit'], ['39.5 %'], ['2113-1-22', '05:17 AM\n'], [], ['TID'], ['GI'], [], ['49 year old'], ['3'], ['5', 'CT'], [], [], [], ['NGT', 'Tube'], [], [], [], [], ['100%', 'Nutren Pulmonary'], ['73'], [], [], ['Identifier 1312'], [], ['40461,Nutrition,"Subjective'], [], [], ['Pantoprazole'], ['Norepinephrine drip'], [], [], [], [], [], ['2113-1-25'], ['BUN'], [], ['2113-1-25'], [], [], ['2113-1-25'], [], [], ['2113-1-25'], [], [], ['2113-1-25'], [], ['108 mEq'], ['2113-1-25'], [], ['26 mEq'], ['2113-1-25'], ['PO2'], ['108 mm'], ['2113-1-25', '03:53 AM'], ['PO2'], ['48 mm'], ['2113-1-21', '05:21 PM'], [], [], ['2113-1-25', '03:53 AM'], [], ['33 mm'], ['2113-1-21', '05:21 PM'], [], ['7.32'], ['2113-1-25', '03:53 AM'], [], ['7.43'], ['2113-1-21', '05:21 PM'], [], ['5.0'], ['2113-1-25', '02:26 PM\n'], ['Calc'], [], ['2113-1-25', '03:53 AM'], ['Calc'], [], ['2113-1-21', '05:21 PM'], [], ['2.1'], ['2113-1-22', '05:17 AM\n'], [], ['7.4'], ['2113-1-25'], [], [], ['2113-1-25'], [], [], ['2113-1-25'], [], [], ['2113-1-22', '05:17 AM\n'], ['Alkaline Phosphate'], [], ['2113-1-22', '05:17 AM\n'], [], [], ['2113-1-22', '05:17 AM\n'], [], ['IU/L'], ['2113-1-22', '05:17 AM\n'], ['Total Bilirubin'], ['0.3'], ['2113-1-22', '05:17 AM\n'], [], [], ['2113-1-25'], ['WBC'], [], ['2113-1-25'], [], ['9.6'], ['2113-1-25'], ['Hematocrit'], ['30.3 %'], ['2113-1-25'], ['Nutren Pulmonary Full'], ['Banana', '3'], ['10 ml', 'Advance', '10 ml q4h Goal', '45 ml'], ['200 ml\n'], ['100 ml', '8 am this morning'], [], ['2113-1-26'], [], ['ND', 'NBS'], ['2+', '2'], [], ['49 year old'], ['3'], ['tomorrow', 'AVR'], ['MVR'], ['12/7-8)'], [], [], [], [], [], [], [], ['10'], [], [], [], [], ['40461,Nutrition,"Ht', '70'], ['57.8 kg'], ['75.3', '77%'], ['BMI', '18.2'], ['1-25'], [], [], [], ['un', '1104', 'Debridement of Aortic Valve'], ['2113-1-23'], [], ['49 year old'], ['CT', 'fx'], [], [], [], [], [], ['40461,Nutrition,"Ht', '70'], ['57.8 kg'], ['75.3', '77%'], ['BMI', '18.2'], ['1-25'], [], [], [], ['un', '1104', 'Debridement of Aortic Valve'], ['2113-1-23'], [], ['49 year old'], ['MV', 'AV'], ['rehab s/p fall'], [], ['5', 'PTA'], [], [], [], ['TID'], ['3', 'Identifier 1372'], [], ['40461,Nutrition,"Subjective'], ['1'], [], [], [], [], [], ['BMI'], ['178 cm'], ['63 kg'], ['72 kg', '2113-2-1', '04:00 AM'], [], ['Ranitidine', 'ABX', 'Folic Acid', 'Thiamine'], ['Multi', 'Colace', '20mEq'], [], [], [], [], [], ['2113-2-1', '03:30 AM\n'], ['Stick'], ['124'], ['2113-2-1', '12:00 AM'], ['BUN'], [], ['2113-2-1', '03:30 AM\n'], [], ['2.0'], ['2113-2-1', '03:30 AM\n'], [], [], ['2113-2-1', '03:30 AM\n'], [], [], ['2113-2-1', '03:30 AM\n'], [], ['105 mEq'], ['2113-2-1', '03:30 AM\n'], [], [], ['2113-2-1', '03:30 AM\n'], ['PO2'], ['65 mm'], ['2113-1-31', '04:47 AM\n'], ['PO2'], ['48 mm'], ['2113-1-21', '05:21 PM'], [], ['30 mm'], ['2113-1-31', '04:47 AM\n'], [], ['33 mm'], ['2113-1-21', '05:21 PM'], [], ['7.46'], ['2113-1-31', '04:47 AM\n'], [], ['7.43'], ['2113-1-21', '05:21 PM'], [], ['5.5'], ['2113-2-1', '07:16 AM\n'], ['Calc'], [], ['2113-1-31', '04:47 AM\n'], ['Calc'], [], ['2113-1-21', '05:21 PM'], [], ['2.2'], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-2-1', '03:30 AM\n'], [], ['4.6'], ['2113-2-1', '03:30 AM\n'], ['Ionized Calcium\n'], ['1.08'], ['2113-1-30', '11:46 AM'], [], ['2.2'], ['2113-2-1', '03:30 AM\n'], [], [], ['2113-1-30', '03:25 AM\n'], ['Alkaline Phosphate'], [], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-1-30', '03:25 AM\n'], ['Total Bilirubin'], ['0.4'], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-1-25'], ['WBC'], [], ['2113-2-1', '03:30 AM\n'], [], ['10.4'], ['2113-2-1', '03:30 AM\n'], ['Hematocrit'], ['31.5 %'], ['2113-2-1', '03:30 AM\n'], [], [], ['2', '2', '2'], ['GI'], [], [], [], ['s/p MVR', '1-27', '1-30', '1-31'], ['1:1', 'MD'], ['RN'], [], ['RN'], ['Calorie', 'today'], [], [], [], [], [], [], [], [], [], [], [], [], [], [], [], [], ['NGT'], [], ['Nutren Pulmonary @', '1620'], ['73'], ['10', 'daily'], ['606'], [], ['40461,Nutrition,"Subjective'], [], [], [], [], [], [], ['BMI'], ['178 cm'], ['63 kg'], ['2113-1-30', '04:00 AM'], [], [], [], [], [], [], [], ['2113-1-30', '07:59 AM\n'], ['Stick'], [], ['2113-1-29', '06:00 PM'], ['BUN'], [], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-1-30', '03:25 AM\n'], [], ['137 mEq'], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-1-30', '03:25 AM\n'], ['PO2'], [], ['2113-1-30', '09:19 AM\n'], ['PO2'], ['48 mm'], ['2113-1-21', '05:21 PM'], [], ['33 mm'], ['2113-1-30', '09:19 AM\n'], [], ['33 mm'], ['2113-1-21', '05:21 PM'], [], ['7.41'], ['2113-1-30', '09:19 AM\n'], [], ['7.43'], ['2113-1-21', '05:21 PM'], [], ['5.0'], ['2113-1-25', '02:26 PM\n'], ['Calc'], [], ['2113-1-30', '09:19 AM\n'], ['Calc'], [], ['2113-1-21', '05:21 PM'], [], ['2.2'], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-1-30', '03:25 AM\n'], [], ['5.2'], ['2113-1-30', '03:25 AM\n'], ['Ionized Calcium\n'], [], ['2113-1-30', '07:59 AM\n'], [], ['2.1'], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-1-30', '03:25 AM\n'], ['Alkaline Phosphate'], [], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-1-30', '03:25 AM\n'], ['Total Bilirubin'], ['0.4'], ['2113-1-30', '03:25 AM\n'], [], [], ['2113-1-25'], ['WBC'], ['11.5'], ['2113-1-30', '03:25 AM\n'], [], ['10.3'], ['2113-1-30', '03:25 AM\n'], ['Hematocrit'], ['30.1 %'], ['2113-1-30', '03:25 AM\n'], ['Nutren Pulmonary Full'], ['10 ml', 'Advance', '10 ml q4h Goal', '50 ml'], ['200 ml\n'], ['30 ml water q4h'], ['GI'], ['2'], [], ['49 year old', '1-15', 's/p MVR'], ['1-27', 'this morning'], ['CCU'], [], ['1 day'], [], [], [], [], [], [], ['Nutren Pulmonary', '45ml'], [], ['10'], [], [], []]
In [27]:
from gensim.models import Word2Vec
model1 = Word2Vec(corpus, min_count=1)
In [29]:
model1.wv['Hematocrit']
Out[29]:
array([-2.3748518e-04, 4.2191767e-03, 2.1141458e-03, 9.9958219e-03,
6.2948110e-04, -5.4644262e-03, -1.1796928e-03, 2.0705319e-03,
-3.3730685e-03, -7.8467671e-03, -5.5992617e-03, -6.7500677e-03,
6.3533271e-03, 3.9225565e-03, 8.2155354e-03, 6.5196683e-03,
-6.1278404e-03, 2.7159513e-03, 8.4721260e-03, 1.5956569e-03,
3.0682290e-03, 5.8126138e-03, -8.8393716e-03, 9.1247475e-03,
6.8194829e-03, 8.5104434e-03, -8.2262624e-03, 6.1755395e-03,
6.6290712e-03, -1.3576425e-03, -6.2938654e-03, 5.3266799e-03,
-6.8595777e-03, -5.3233542e-03, 3.5116898e-03, 8.0809724e-03,
8.6926939e-03, -4.4053150e-03, -9.1887703e-03, 9.6076941e-03,
6.2903082e-03, -3.9663352e-03, -8.4597291e-03, -4.7183349e-03,
-3.9572273e-03, -3.2734512e-03, 8.1909180e-04, -2.9716254e-04,
-3.1123769e-03, -5.9959874e-03, 9.4205197e-03, -4.7255373e-03,
-7.2620986e-03, 7.6847305e-03, 2.5176955e-03, 8.6263958e-03,
-4.4651162e-03, -6.8924036e-03, 9.8490238e-04, -1.1729765e-03,
-9.3970643e-03, -1.6030729e-03, 3.0505990e-03, 6.5657818e-03,
6.8452419e-03, 3.2082784e-03, -4.4432725e-03, -1.8391669e-03,
-3.9402582e-03, 5.7739150e-03, -6.3587092e-03, 2.1030188e-03,
-1.3452339e-03, -5.8127786e-03, -7.2462116e-03, 5.8525624e-03,
-8.3582047e-03, -6.8724988e-04, 2.8274262e-03, 7.7390098e-03,
-7.2979080e-03, 3.3045732e-03, 9.8084975e-03, -6.9770790e-03,
-3.5348581e-03, 5.1335134e-03, 5.2383854e-03, 1.6241145e-03,
7.9711350e-03, 8.3158852e-04, 1.8713165e-03, -1.6052496e-03,
-8.1662778e-03, 3.2578039e-03, 1.9663644e-03, -8.7342048e-03,
-6.7500712e-04, 7.6670643e-05, -5.9592726e-06, 8.7101338e-03],
dtype=float32)
In [30]:
model1.wv.similar_by_word('Hematocrit')
Out[30]:
[('10.4', 0.3077991008758545),
('65 kg', 0.26820874214172363),
('100 ml', 0.2433023303747177),
('151', 0.23261547088623047),
('Diet', 0.22584640979766846),
('60', 0.224870964884758),
('38 mm', 0.22341559827327728),
('10.3', 0.21017244458198547),
('Goal', 0.2089768797159195),
('07:16 AM\n', 0.20850542187690735)]
In [31]:
def tsne_plot(model,words, preTrained=False):
"Creates and TSNE model and plots it"
labels = []
tokens = []
for word in words:
if preTrained:
tokens.append(model[word])
else:
tokens.append(model.wv[word])
labels.append(word)
tokens = np.array(tokens)
tsne_model = TSNE(perplexity=30, early_exaggeration=12, n_components=2, init='pca', n_iter=1000, random_state=23)
new_values = tsne_model.fit_transform(tokens)
x = []
y = []
for value in new_values:
x.append(value[0])
y.append(value[1])
plt.figure(figsize=(16, 16))
for i in range(len(x)):
plt.scatter(x[i],y[i])
plt.annotate(labels[i],
xy=(x[i], y[i]),
xytext=(5, 2),
textcoords='offset points',
ha='right',
va='bottom')
plt.show()
In [33]:
from sklearn.manifold import TSNE
vocabs = model1.wv.key_to_index.keys()
new_v = np.array(list(vocabs))
tsne_plot(model1,new_v)
In [34]:
# load pre-trained word2vec embeddings
import gensim
import gensim.downloader as api
info = api.info() # show info about available models/datasets
pretrained_model= api.load("glove-wiki-gigaword-50") # download the model and return as object ready for use
# pretrained_model = gensim.models.KeyedVectors.load_word2vec_format('PubMed-and-PMC-ri.tar.gz', binary=True)
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In [36]:
corpus_in_pretrained_model = []
for word in vocabs:
if word in pretrained_model:
corpus_in_pretrained_model.append(word)
else:
print(word) #
2172-11-2 2113-1-30 2113-1-20 2100-11-1 05:21 PM 2113-1-21 2113-1-22 02:37 AM 2113-1-25 2113-2-3 05:17 AM 03:25 AM PO2 Calc 05:24 AM 2113-2-1 12:18 PM 04:47 AM 2113-1-31 2113-2-6 BUN WBC Hematocrit 04:05 AM 2100-11-5 2172-11-9 BMI 2113-2-7 2113-2-4 03:30 AM Stick Alkaline Phosphate 03:42 AM Total Bilirubin 2113-2-8 TF NPO Ionized Calcium 49 year old 2172-10-31 02:55 AM 63 kg 40461,Nutrition,"Subjective 11:55 AM 178 cm 01:50 AM 04:00 AM 03:32 AM GI 33 mm 2181-6-4 02:50 AM 04:51 PM CT 2113-1-15 NGT 48 mm IU/L 04:35 AM 11:36 PM 08:00 AM MD 01:06 AM 200 ml PEG 65 mm 137 mEq 30 mm PMH 2181-6-5 IU/L 07:16 AM 111 mEq IV 04:00 AM 09:19 AM 2100-10-31 Advance 07:26 AM 11:46 AM 2100-11-4 2113-1-18 45ml BEE 1.2-1.4 03:53 AM Thiamine s/p MVR Nutren Pulmonary 12:22 AM 75.3 kg this morning 26 mEq Bowel 61565,Nutrition,"Objective 10 ml 142 mEq 3.9 mEq 65 ml Identifier 1372 12:03 AM 168 cm 41 mm 2172-11-1 06:06 PM Nafcillin 02:31 AM 1.3 g/kg 05:19 PM 07:52 AM 08:00 PM 40 ml Identifier 1550 First 22-25 cal/kg PTA Heparin Cont Bg 109 mm Phenytoin 02:44 PM 12:00 PM Dilantin 02:34 AM Colace 2100-10-30 33.9 % Isosource 1.5 Folic Acid ABX 38 mm Multi Ranitidine Goal 15 ml 20mEq 3.6 mEq 64.4 kg 101% NKFA LR @ 10 72 kg 146 mEq 113 mm 1620kcal/73.4 76-88 1575-1764 35.2 % 07:15 AM TID 02:00 AM 12:03 PM 77% 07:59 AM RN 2113-1-23 Debridement of Aortic Valve Identifier 1684 57.8 kg 40461,Nutrition,"Ht 10 ml q4h Goal Nutren Pulmonary Full 100% 02:26 PM 65 kg 78-91 Likely Adequate TPN 57 year old OSH 65ml 34 mm 88.2 kg 117% Esmolol 30 ml water q8h 2100-11-1* Identifier 2584 Nicotine Patch 1625-[**2114 30 years 119% 2113-1-19 70.5 kg 45 ml 145 mm 12:00 AM 108 mEq 27.2 % 85% CATEGORY 40493,Nutrition,"Objective Identifier 5307 Diet 37 mm 17610,Nutrition,"Patient 88% IVC TEXT Replete c/ Fiber @65mL MICU 33.8 % 11:05 AM SS Replete with Fiber 2172-11-3 SLP- earlier today Abd soft/+bs 01:34 PM 2172-11-5 02:24 AM 2027**]-2200 Abx 1760-2200 20-25 cal/kg 1800kcal/112 66 mm 75 mL 1 day BG Norepinephrine drip last night 05:48 PM 10:00 AM 4.3 mEq 61 mm 31 mm 06:24 PM 39.5 % Tube Identifier 1312 NI Createnine 29.7 % 15ml D5 40 mEq PPN ARF PA Monday Isosource HN @ Physician Note this day Pantoprazole 108 mm Isosource 1.5cal 31.5 % Calorie Nutren Pulmonary @ 2113-1-29 06:00 PM 30.1 % 50 ml 30 ml water q4h 105 mEq ND 30.3 % Banana 100 ml 8 am this morning 2113-1-26 NBS rehab s/p fall 2+ AVR MVR 12/7-8) MV AV 1620kcal/73 1 TPN Coumadin 09:13 AM 2181-6-3 12:30 AM 32.7 % Obese 1513-1720 1.2-1.5 78 year old S/P Le Forte 4-6 hours 5% Dextrose 99573,Nutrition,"Subjective O2 PACU 24-48hrs Identifier 1687 58054,Nutrition,"Comments Identifier 2337 XRT 30 mEq 98.2 kg 59 kg 166% 68.8 kg polymyalgia NIDDM greater than 150 Lasix the weekend CCU Fibersource 1728kcal/76 70.8 kg Multiple Vitamins 06:00 AM 145 mEq 11:00 PM 26.9 % 270drextrose/80protein/35fat 10 ml q6h Goal 60 ml Peg Mitral S & S s/p PEG 70 ml 20 ml First Name4 27.0 % 17 - 18 29mm 26.1 % thin liquid PRN 10:00 PM SUBJECT_ID
In [37]:
tsne_plot(pretrained_model,corpus_in_pretrained_model,True)
In [38]:
# Entity Visualizer
from spacy import displacy
for i in range(len(doc)):
displacy.render(doc[i], style="ent", jupyter=True)
print('*********************************************************************************************************************************************************************')
SUBJECT_ID
GPE
,
CATEGORY
NORP
,
TEXT
PERSON
*********************************************************************************************************************************************************************
17610,Nutrition,"Patient
CARDINAL
transferred to
MICU
ORG
for concern for aspiration.
Diet
ORG
changed
*********************************************************************************************************************************************************************
to
NPO
ORG
;
NGT
ORG
in for medication. Noted plan to transition to comfort
*********************************************************************************************************************************************************************
focused care.
*********************************************************************************************************************************************************************
Will sign off at this time. Please consult if needed. Pager *[**Numeric
Identifier 5307
DATE
**]
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
40493,Nutrition,"Objective
CARDINAL
*********************************************************************************************************************************************************************
Pertinent medications: RISS,
SS
ORG
lytes, thiamin, folate, lasix, bowel
*********************************************************************************************************************************************************************
regimen, MOM, reglan, others noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
93 mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**]
01:50 AM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
120
CARDINAL
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**] 08:57 AM
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
15 mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**]
01:50 AM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
0.6 mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**]
01:50 AM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
137 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**]
01:50 AM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
3.9 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**]
01:50 AM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
106 mEq/L
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**]
01:50 AM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
24 mEq/L
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**]
01:50 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(arterial)
*********************************************************************************************************************************************************************
66 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**] 08:57 AM
*********************************************************************************************************************************************************************
PCO2 (arterial)
*********************************************************************************************************************************************************************
41 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**] 08:57 AM
*********************************************************************************************************************************************************************
pH (arterial)
*********************************************************************************************************************************************************************
7.42
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**] 08:57 AM
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
5.0
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2172-11-1
DATE
**]
06:06 PM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) arterial
*********************************************************************************************************************************************************************
28 mEq/L
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**] 08:57 AM
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
2.6 g/dL
*********************************************************************************************************************************************************************
[**
2172-11-3
DATE
**]
02:24 AM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
8.7 mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**]
01:50 AM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
4.5 mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**]
01:50 AM
TIME
*********************************************************************************************************************************************************************
Ionized Calcium
WORK_OF_ART
*********************************************************************************************************************************************************************
1.11
CARDINAL
mmol/L
*********************************************************************************************************************************************************************
[**
2172-11-5
DATE
**]
01:34 PM
TIME
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
2.2
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-9
DATE
**]
01:50 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support: Fibersource HN@60mL/hr (
1728
DATE
*********************************************************************************************************************************************************************
kcals/73 gr aa) not infusing
*********************************************************************************************************************************************************************
GI:
Abd soft/+bs
PERSON
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
Specifics:
*********************************************************************************************************************************************************************
Pt extubated
earlier today
TIME
. Pt was previously tolerating
TF
GPE
*********************************************************************************************************************************************************************
s @ goal,
*********************************************************************************************************************************************************************
meeting
100%
PERCENT
estimated nutrition needs. Anticipate diet advancement as
*********************************************************************************************************************************************************************
able.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
Advance diet per team c/ swallow eval if pt shows s/s of aspiration and
*********************************************************************************************************************************************************************
advance diet per
SLP-
PRODUCT
vs place
NGT
ORG
and resume
TF
ORG
's if unable to take
*********************************************************************************************************************************************************************
po
*********************************************************************************************************************************************************************
Will follow plan -please page c/ ?'s #[**Numeric
Identifier 1684
DATE
**]
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
40493,Nutrition,"Subjective
*********************************************************************************************************************************************************************
intubated
*********************************************************************************************************************************************************************
Objective
*********************************************************************************************************************************************************************
Height
*********************************************************************************************************************************************************************
Admit weight
*********************************************************************************************************************************************************************
Daily weight
*********************************************************************************************************************************************************************
Weight change
*********************************************************************************************************************************************************************
BMI
ORG
*********************************************************************************************************************************************************************
168 cm
QUANTITY
*********************************************************************************************************************************************************************
65 kg
QUANTITY
*********************************************************************************************************************************************************************
23.1
CARDINAL
*********************************************************************************************************************************************************************
Ideal body weight
*********************************************************************************************************************************************************************
% Ideal body weight
*********************************************************************************************************************************************************************
Adjusted weight
*********************************************************************************************************************************************************************
Usual body weight
*********************************************************************************************************************************************************************
% Usual body weight
*********************************************************************************************************************************************************************
64.4 kg
QUANTITY
*********************************************************************************************************************************************************************
101%
PERCENT
*********************************************************************************************************************************************************************
Diagnosis: S/P Fall
*********************************************************************************************************************************************************************
PMH
ORG
: etoh, smoker, cirrhosis
*********************************************************************************************************************************************************************
Food allergies and intolerances:
NKFA
ORG
*********************************************************************************************************************************************************************
Pertinent medications: fentanyl,
LR @ 10
ORG
ml/hr, lasix, versed, RISS,
IV
GPE
*********************************************************************************************************************************************************************
abx, others noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
155
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
151
CARDINAL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
08:00 AM
TIME
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
17 mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
0.8
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
146 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
3.6 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
111 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
29 mEq/L
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(arterial)
*********************************************************************************************************************************************************************
113 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
11:55 AM
TIME
*********************************************************************************************************************************************************************
PCO2 (arterial)
*********************************************************************************************************************************************************************
41 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
11:55 AM
TIME
*********************************************************************************************************************************************************************
pH (arterial)
*********************************************************************************************************************************************************************
7.46
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
11:55 AM
TIME
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
5.0
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2172-11-1
DATE
**]
06:06 PM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) arterial
*********************************************************************************************************************************************************************
30 mEq/L
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
11:55 AM
TIME
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
3.0
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2172-10-31
DATE
**]
02:55 AM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
8.1
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
2.5 mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Ionized Calcium
WORK_OF_ART
*********************************************************************************************************************************************************************
1.16
CARDINAL
mmol/L
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
11:55 AM
TIME
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
1.7
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
ALT
*********************************************************************************************************************************************************************
14 IU/L
*********************************************************************************************************************************************************************
[**
2172-10-31
DATE
**]
02:55 AM
TIME
*********************************************************************************************************************************************************************
Alkaline Phosphate
ORG
*********************************************************************************************************************************************************************
73
IU/L
EVENT
*********************************************************************************************************************************************************************
[**
2172-10-31
DATE
**]
02:55 AM
TIME
*********************************************************************************************************************************************************************
AST
*********************************************************************************************************************************************************************
43 IU/L
*********************************************************************************************************************************************************************
[**
2172-10-31
DATE
**]
02:55 AM
TIME
*********************************************************************************************************************************************************************
Total Bilirubin
PERSON
*********************************************************************************************************************************************************************
3.4 mg/dL
*********************************************************************************************************************************************************************
[**
2172-10-31
DATE
**]
02:55 AM
TIME
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
23.2 K/uL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
01:06 AM
TIME
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
9.1
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
01:06 AM
TIME
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
27.2 %
PERCENT
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
01:06 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support: NPO replete with fiber @
60
CARDINAL
*********************************************************************************************************************************************************************
ml/hr
*********************************************************************************************************************************************************************
GI
ORG
: OGT
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
At risk for malnutrition
*********************************************************************************************************************************************************************
Pt at risk due to:
NPO
ORG
/ hypocaloric diet
*********************************************************************************************************************************************************************
Estimated Nutritional Needs
*********************************************************************************************************************************************************************
Calories:
1625-[**2114
CARDINAL
**] (
25-30
TIME
cal/kg)
*********************************************************************************************************************************************************************
Protein:
78-91
CARDINAL
(
1.2-1.4
CARDINAL
g/kg)
*********************************************************************************************************************************************************************
Fluid: per team
*********************************************************************************************************************************************************************
Estimation of previous intake:
Likely Adequate
WORK_OF_ART
*********************************************************************************************************************************************************************
Estimation of current intake: Inadequate
*********************************************************************************************************************************************************************
Specifics:
57 year old
DATE
male transferred from
OSH
ORG
, intubated there. Pt
*********************************************************************************************************************************************************************
S/P fall
CT
ORG
shows Stage IV splenic laceration. Tolerating TF with
*********************************************************************************************************************************************************************
minimal residuals [**Name8 (
MD
GPE
) **] RN. Current
TF
ORG
provides
1440
DATE
kcals/89 g Pro.
*********************************************************************************************************************************************************************
Recommend changing TF to better meet nutritional needs.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
1. Check chemistry
10
CARDINAL
panel
daily
DATE
*********************************************************************************************************************************************************************
2. Change TF to goal of Fibersource HN @
65ml
ORDINAL
/hr (
1872
DATE
kcals/83 g
*********************************************************************************************************************************************************************
Pro)
*********************************************************************************************************************************************************************
3
CARDINAL
. Pls page with questions [**Numeric
Identifier 2584
DATE
**]
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
40493,Nutrition,"Subjective
*********************************************************************************************************************************************************************
intubated
*********************************************************************************************************************************************************************
Objective
*********************************************************************************************************************************************************************
Height
*********************************************************************************************************************************************************************
Admit weight
*********************************************************************************************************************************************************************
Daily weight
*********************************************************************************************************************************************************************
Weight change
*********************************************************************************************************************************************************************
BMI
ORG
*********************************************************************************************************************************************************************
168 cm
QUANTITY
*********************************************************************************************************************************************************************
65 kg
QUANTITY
*********************************************************************************************************************************************************************
23.1
CARDINAL
*********************************************************************************************************************************************************************
Ideal body weight
*********************************************************************************************************************************************************************
% Ideal body weight
*********************************************************************************************************************************************************************
Adjusted weight
*********************************************************************************************************************************************************************
Usual body weight
*********************************************************************************************************************************************************************
% Usual body weight
*********************************************************************************************************************************************************************
64.4 kg
QUANTITY
*********************************************************************************************************************************************************************
101%
PERCENT
*********************************************************************************************************************************************************************
Diagnosis: S/P Fall
*********************************************************************************************************************************************************************
PMH
ORG
: etoh, smoker, cirrhosis
*********************************************************************************************************************************************************************
Food allergies and intolerances:
NKFA
ORG
*********************************************************************************************************************************************************************
Pertinent medications: fentanyl,
LR @ 10
ORG
ml/hr, lasix, versed, RISS,
IV
GPE
*********************************************************************************************************************************************************************
abx, others noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
155
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
151
CARDINAL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
08:00 AM
TIME
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
17 mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
0.8
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
146 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
3.6 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
111 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
29 mEq/L
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(arterial)
*********************************************************************************************************************************************************************
113 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
11:55 AM
TIME
*********************************************************************************************************************************************************************
PCO2 (arterial)
*********************************************************************************************************************************************************************
41 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
11:55 AM
TIME
*********************************************************************************************************************************************************************
pH (arterial)
*********************************************************************************************************************************************************************
7.46
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
11:55 AM
TIME
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
5.0
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2172-11-1
DATE
**]
06:06 PM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) arterial
*********************************************************************************************************************************************************************
30 mEq/L
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
11:55 AM
TIME
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
3.0
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2172-10-31
DATE
**]
02:55 AM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
8.1
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
2.5 mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
Ionized Calcium
WORK_OF_ART
*********************************************************************************************************************************************************************
1.16
CARDINAL
mmol/L
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
11:55 AM
TIME
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
1.7
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
12:18 PM
TIME
*********************************************************************************************************************************************************************
ALT
*********************************************************************************************************************************************************************
14 IU/L
*********************************************************************************************************************************************************************
[**
2172-10-31
DATE
**]
02:55 AM
TIME
*********************************************************************************************************************************************************************
Alkaline Phosphate
ORG
*********************************************************************************************************************************************************************
73
IU/L
EVENT
*********************************************************************************************************************************************************************
[**
2172-10-31
DATE
**]
02:55 AM
TIME
*********************************************************************************************************************************************************************
AST
*********************************************************************************************************************************************************************
43 IU/L
*********************************************************************************************************************************************************************
[**
2172-10-31
DATE
**]
02:55 AM
TIME
*********************************************************************************************************************************************************************
Total Bilirubin
PERSON
*********************************************************************************************************************************************************************
3.4 mg/dL
*********************************************************************************************************************************************************************
[**
2172-10-31
DATE
**]
02:55 AM
TIME
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
23.2 K/uL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
01:06 AM
TIME
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
9.1
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
01:06 AM
TIME
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
27.2 %
PERCENT
*********************************************************************************************************************************************************************
[**
2172-11-2
DATE
**]
01:06 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support: NPO replete with fiber @
60
CARDINAL
*********************************************************************************************************************************************************************
ml/hr
*********************************************************************************************************************************************************************
GI
ORG
: OGT
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
At risk for malnutrition
*********************************************************************************************************************************************************************
Pt at risk due to:
NPO
ORG
/ hypocaloric diet
*********************************************************************************************************************************************************************
Estimated Nutritional Needs
*********************************************************************************************************************************************************************
Calories:
1625-[**2114
CARDINAL
**] (
25-30
TIME
cal/kg)
*********************************************************************************************************************************************************************
Protein:
78-91
CARDINAL
(
1.2-1.4
CARDINAL
g/kg)
*********************************************************************************************************************************************************************
Fluid: per team
*********************************************************************************************************************************************************************
Estimation of previous intake:
Likely Adequate
WORK_OF_ART
*********************************************************************************************************************************************************************
Estimation of current intake: Inadequate
*********************************************************************************************************************************************************************
Specifics:
57 year old
DATE
male transferred from
OSH
ORG
, intubated there. Pt
*********************************************************************************************************************************************************************
S/P fall
CT
ORG
shows Stage IV splenic laceration. Tolerating TF with
*********************************************************************************************************************************************************************
minimal residuals [**Name8 (
MD
GPE
) **] RN. Current
TF
ORG
provides
1440
DATE
kcals/89 g Pro.
*********************************************************************************************************************************************************************
Recommend changing TF to better meet nutritional needs.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
1. Check chemistry
10
CARDINAL
panel
daily
DATE
*********************************************************************************************************************************************************************
2. Change TF to goal of Fibersource HN @
65ml
ORDINAL
/hr (
1872
DATE
kcals/83 g
*********************************************************************************************************************************************************************
Pro)
*********************************************************************************************************************************************************************
3
CARDINAL
. Pls page with questions [**Numeric
Identifier 2584
DATE
**]
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
61565,Nutrition,"Objective
CARDINAL
*********************************************************************************************************************************************************************
Height
*********************************************************************************************************************************************************************
Admit weight
*********************************************************************************************************************************************************************
Daily weight
*********************************************************************************************************************************************************************
Weight change
*********************************************************************************************************************************************************************
BMI
ORG
*********************************************************************************************************************************************************************
178 cm
QUANTITY
*********************************************************************************************************************************************************************
88.2 kg
QUANTITY
*********************************************************************************************************************************************************************
27.8
CARDINAL
*********************************************************************************************************************************************************************
Ideal body weight
*********************************************************************************************************************************************************************
% Ideal body weight
*********************************************************************************************************************************************************************
Adjusted weight
*********************************************************************************************************************************************************************
Usual body weight
*********************************************************************************************************************************************************************
% Usual body weight
*********************************************************************************************************************************************************************
75.3 kg
QUANTITY
*********************************************************************************************************************************************************************
117%
PERCENT
*********************************************************************************************************************************************************************
Diagnosis: Head Bleed
*********************************************************************************************************************************************************************
PMH
ORG
: DM.
*********************************************************************************************************************************************************************
Food allergies and intolerances:
*********************************************************************************************************************************************************************
Pertinent medications:
Esmolol
PERSON
, famotidine, colace, lytes ss,
dilantin
PERSON
,
*********************************************************************************************************************************************************************
ssri, others noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
143 mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
155
CARDINAL
*********************************************************************************************************************************************************************
[**
2100-11-1*
DATE
*]
02:00 AM
TIME
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
18 mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
0.8
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
142 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
4.1 mEq/L
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
111 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
26 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(arterial)
*********************************************************************************************************************************************************************
109 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
04:35 AM
TIME
*********************************************************************************************************************************************************************
PCO2 (arterial)
*********************************************************************************************************************************************************************
38 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
04:35 AM
TIME
*********************************************************************************************************************************************************************
pH (arterial)
*********************************************************************************************************************************************************************
7.48
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
04:35 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) arterial
*********************************************************************************************************************************************************************
29 mEq/L
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
04:35 AM
TIME
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
3.8
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2100-10-30
DATE
**] 03:27 AM
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
8.9
MONEY
mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
2.5 mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Ionized Calcium
WORK_OF_ART
*********************************************************************************************************************************************************************
1.22
CARDINAL
mmol/L
*********************************************************************************************************************************************************************
[**
2100-10-31
DATE
**] 02:41 AM
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
2.3 mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Phenytoin
PERSON
(
Dilantin
PERSON
)
*********************************************************************************************************************************************************************
10.1 ug/mL
*********************************************************************************************************************************************************************
[**
2100-10-31
DATE
**]
02:34 AM
TIME
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
12.1
CARDINAL
K/uL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
11.9
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
33.9 %
PERCENT
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support: Replete with fiber Full
*********************************************************************************************************************************************************************
strength;
Goal
PERSON
rate:
65 ml
QUANTITY
/hr
*********************************************************************************************************************************************************************
Residual Check: q4h Hold feeding for residual >= :
200 ml
QUANTITY
*********************************************************************************************************************************************************************
GI
ORG
:
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
At risk for malnutrition
*********************************************************************************************************************************************************************
Pt at risk due to:
NPO
ORG
/ hypocaloric diet
*********************************************************************************************************************************************************************
Estimated Nutritional Needs
*********************************************************************************************************************************************************************
Calories: [**
2027**]-2200
CARDINAL
(
BEE
ORG
x or /
22-25 cal/kg
QUANTITY
)
*********************************************************************************************************************************************************************
Protein:
114
CARDINAL
(
1.3 g/kg
QUANTITY
)
*********************************************************************************************************************************************************************
Fluid:
*********************************************************************************************************************************************************************
Estimation of previous intake: Adequate
*********************************************************************************************************************************************************************
Estimation of current intake: Inadequate
*********************************************************************************************************************************************************************
Specifics:
*********************************************************************************************************************************************************************
72 yo male s/p witnessed fall w/ head trauma, right parietal-occipital
*********************************************************************************************************************************************************************
SAH w/ left intraparenchymal bleed / contre-coup injury. Pt started on
*********************************************************************************************************************************************************************
TF
GPE
yesterday
DATE
, currently tol goal TF without issue, per chart, pt with +
*********************************************************************************************************************************************************************
gag, will plan to extubate this am. If unable to extubate, will need
*********************************************************************************************************************************************************************
to change
TF
ORG
to better meet pt's needs.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
Tube feeding recommendations:
*********************************************************************************************************************************************************************
Check chemistry
10
CARDINAL
panel
daily
DATE
and replete
*********************************************************************************************************************************************************************
Cont Bg
PERSON
management
*********************************************************************************************************************************************************************
Pplease page [**Numeric
Identifier 1550
DATE
**] if has ?
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
61565,Nutrition,"Objective
CARDINAL
*********************************************************************************************************************************************************************
Height
*********************************************************************************************************************************************************************
Admit weight
*********************************************************************************************************************************************************************
Daily weight
*********************************************************************************************************************************************************************
Weight change
*********************************************************************************************************************************************************************
BMI
ORG
*********************************************************************************************************************************************************************
178 cm
QUANTITY
est.
*********************************************************************************************************************************************************************
88.2 kg
QUANTITY
*********************************************************************************************************************************************************************
27.8
CARDINAL
*********************************************************************************************************************************************************************
Ideal body weight
*********************************************************************************************************************************************************************
% Ideal body weight
*********************************************************************************************************************************************************************
Adjusted weight
*********************************************************************************************************************************************************************
Usual body weight
*********************************************************************************************************************************************************************
% Usual body weight
*********************************************************************************************************************************************************************
75.3 kg
QUANTITY
*********************************************************************************************************************************************************************
117%
PERCENT
*********************************************************************************************************************************************************************
Diagnosis: Head Bleed
*********************************************************************************************************************************************************************
PMH
ORG
: DM, HTN
*********************************************************************************************************************************************************************
Food allergies and intolerances:
*********************************************************************************************************************************************************************
Pertinent medications:
Esmolol
PERSON
, famotidine, colace, lytes ss,
dilantin
PERSON
,
*********************************************************************************************************************************************************************
ssri, others noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
143 mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
155
CARDINAL
*********************************************************************************************************************************************************************
[**
2100-11-1*
DATE
*]
02:00 AM
TIME
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
18 mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
0.8
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
142 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
4.1 mEq/L
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
111 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
26 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(arterial)
*********************************************************************************************************************************************************************
109 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
04:35 AM
TIME
*********************************************************************************************************************************************************************
PCO2 (arterial)
*********************************************************************************************************************************************************************
38 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
04:35 AM
TIME
*********************************************************************************************************************************************************************
pH (arterial)
*********************************************************************************************************************************************************************
7.48
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
04:35 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) arterial
*********************************************************************************************************************************************************************
29 mEq/L
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
04:35 AM
TIME
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
3.8
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2100-10-30
DATE
**] 03:27 AM
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
8.9
MONEY
mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
2.5 mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Ionized Calcium
WORK_OF_ART
*********************************************************************************************************************************************************************
1.22
CARDINAL
mmol/L
*********************************************************************************************************************************************************************
[**
2100-10-31
DATE
**] 02:41 AM
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
2.3 mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Phenytoin
PERSON
(
Dilantin
PERSON
)
*********************************************************************************************************************************************************************
10.1 ug/mL
*********************************************************************************************************************************************************************
[**
2100-10-31
DATE
**]
02:34 AM
TIME
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
12.1
CARDINAL
K/uL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
11.9
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
33.9 %
PERCENT
*********************************************************************************************************************************************************************
[**
2100-11-1
DATE
**]
02:37 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support: Replete with fiber Full
*********************************************************************************************************************************************************************
strength;
Goal
PERSON
rate:
65 ml
QUANTITY
/hr (1560kcal/96.7g pro)
*********************************************************************************************************************************************************************
Residual Check: q4h Hold feeding for residual >= :
200 ml
QUANTITY
*********************************************************************************************************************************************************************
GI: Soft, Non-distended, Non-tender
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
At risk for malnutrition
*********************************************************************************************************************************************************************
Pt at risk due to: NPO
*********************************************************************************************************************************************************************
Estimated Nutritional Needs
*********************************************************************************************************************************************************************
Calories:
1760-2200
DATE
(
BEE
ORG
x or /
20-25 cal/kg
TIME
)
*********************************************************************************************************************************************************************
Protein:
114
CARDINAL
(
1.3 g/kg
QUANTITY
)
*********************************************************************************************************************************************************************
Fluid: per team
*********************************************************************************************************************************************************************
Estimation of previous intake: likely adequate
*********************************************************************************************************************************************************************
Estimation of current intake: Inadequate
*********************************************************************************************************************************************************************
Specifics:
*********************************************************************************************************************************************************************
72 yo male s/p witnessed fall w/ head trauma, right parietal-occipital
*********************************************************************************************************************************************************************
SAH w/ left intraparenchymal bleed / contre-coup injury. Pt started on
*********************************************************************************************************************************************************************
TF
GPE
yesterday
DATE
, currently tol goal TF without issue, per chart, pt with +
*********************************************************************************************************************************************************************
gag, cough, [**Last Name (LF)
1080
CARDINAL
**], [**
First
ORDINAL
Name3 (LF) **] plan to extubate this am. If unable to
*********************************************************************************************************************************************************************
extubate, will need to change
TF
ORG
to better meet pt's needs.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
Tube feeding recommendations: increase TF to
Replete with Fiber
ORG
goal
*********************************************************************************************************************************************************************
75ml/hr (
1800kcal/112
CARDINAL
g pro)
*********************************************************************************************************************************************************************
Check chemistry
10
CARDINAL
panel
daily
DATE
and replete prn
*********************************************************************************************************************************************************************
Cont Bg
PERSON
management
*********************************************************************************************************************************************************************
Please page [**Numeric
Identifier 1550
DATE
**] if has ?
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
61565,Nutrition,"Objective
CARDINAL
*********************************************************************************************************************************************************************
Pertinent medications: pepcid,
Heparin
NORP
, docusate,
Abx
PERSON
, RISS, others
*********************************************************************************************************************************************************************
noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
128
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
03:32 AM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
140
CARDINAL
*********************************************************************************************************************************************************************
[**
2100-11-4
DATE
**]
08:00 PM
TIME
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
18 mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
03:32 AM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
0.7
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
03:32 AM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
140 mEq/L
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
03:32 AM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
3.9 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
03:32 AM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
103 mEq/L
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
03:32 AM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
28 mEq/L
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
03:32 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(arterial)
*********************************************************************************************************************************************************************
94.[**Numeric Identifier 126**] mm Hg
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
07:26 AM
TIME
*********************************************************************************************************************************************************************
PCO2 (arterial)
*********************************************************************************************************************************************************************
37 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
07:26 AM
TIME
*********************************************************************************************************************************************************************
pH (arterial)
*********************************************************************************************************************************************************************
7.49
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
07:26 AM
TIME
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
7.0
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
11:05 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) arterial
*********************************************************************************************************************************************************************
29 mEq/L
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
07:26 AM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
8.7 mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-4
DATE
**]
02:31 AM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
3.0 mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-4
DATE
**]
02:31 AM
TIME
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
2.3 mg/dL
*********************************************************************************************************************************************************************
[**
2100-11-4
DATE
**]
02:31 AM
TIME
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
12.2 K/uL
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
03:32 AM
TIME
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
12.0
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
03:32 AM
TIME
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
33.8 %
PERCENT
*********************************************************************************************************************************************************************
[**
2100-11-5
DATE
**]
03:32 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support:
Replete c/ Fiber @65mL
ORG
/hr (
1560
DATE
*********************************************************************************************************************************************************************
kcals/97 gr aa)
*********************************************************************************************************************************************************************
GI: Abd: soft/+bs
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
Estimation of current intake: Inadequate
*********************************************************************************************************************************************************************
Specifics:
*********************************************************************************************************************************************************************
Pt s/p trach/PEG/and
IVC
ORG
filter
yesterday
DATE
.
TF
GPE
*********************************************************************************************************************************************************************
s currently infusing @
*********************************************************************************************************************************************************************
10mL/hr. Current goal Rx will meet
88%
PERCENT
estimated kcal and
85%
PERCENT
estimated
*********************************************************************************************************************************************************************
aa needs therefore, will need to increase goal rate of
TF
GPE
*********************************************************************************************************************************************************************
s to avoid
*********************************************************************************************************************************************************************
underfeeding. .
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
Multivitamin / Mineral supplement: vua
TF
GPE
*********************************************************************************************************************************************************************
Tube feeding recommendations: Increase TF goal rate to
75 mL
QUANTITY
/hr (
1800
CARDINAL
*********************************************************************************************************************************************************************
kcals/112 gr aa)
*********************************************************************************************************************************************************************
BG
GPE
management as you are
*********************************************************************************************************************************************************************
Please page c/?'s #[**Numeric
Identifier 1684
DATE
**]
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
98851,Nutrition,"Patient has been
NPO
ORG
and/or on unsupplemented clear liquid diet for
1
CARDINAL
*********************************************************************************************************************************************************************
days. If patient's diet is not able to be advanced and tolerated,
*********************************************************************************************************************************************************************
[**Street Address(1)
1511
DATE
**] for nutrition support
*********************************************************************************************************************************************************************
Potential for nutrition risk. Patient being monitored. Current
*********************************************************************************************************************************************************************
intervention if any, listed below:
*********************************************************************************************************************************************************************
Comments:
*********************************************************************************************************************************************************************
Pt s/p LRRT [**
4-17
CARDINAL
**], c/b hypoxia and increased
O2
CARDINAL
requirements in
PACU
GPE
, on
*********************************************************************************************************************************************************************
clears, tolerating well. Clinically improving, possibly transfer to
*********************************************************************************************************************************************************************
floor soon.
*********************************************************************************************************************************************************************
If unable to advance diet further in
24-48hrs
CARDINAL
, patient may benefit from
*********************************************************************************************************************************************************************
nutrition support.
*********************************************************************************************************************************************************************
Will f/u with progress, po tolerance.
*********************************************************************************************************************************************************************
Please page w/ questions #[**Numeric
Identifier 1687
DATE
**]
*********************************************************************************************************************************************************************
12:11
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
58054,Nutrition,"Comments
CARDINAL
:
*********************************************************************************************************************************************************************
Screening per hospital nutrition protocol. Noted patient is comfort
*********************************************************************************************************************************************************************
measures only. No nutrition support indicated at this time. Will sign
*********************************************************************************************************************************************************************
off. Please consult if needed. #[**Numeric
Identifier 2337
DATE
**]
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
99573,Nutrition,"Subjective
CARDINAL
*********************************************************************************************************************************************************************
patient confused, unable to answer questions per chart patient had
*********************************************************************************************************************************************************************
difficulty swallowing
PTA
ORG
d/t damaged salivary glands from
XRT
ORG
*********************************************************************************************************************************************************************
Objective
*********************************************************************************************************************************************************************
Height
*********************************************************************************************************************************************************************
Admit weight
*********************************************************************************************************************************************************************
Daily weight
*********************************************************************************************************************************************************************
Weight change
*********************************************************************************************************************************************************************
BMI
ORG
*********************************************************************************************************************************************************************
168 cm
QUANTITY
*********************************************************************************************************************************************************************
98.2 kg
QUANTITY
*********************************************************************************************************************************************************************
34.9
CARDINAL
*********************************************************************************************************************************************************************
Ideal body weight
*********************************************************************************************************************************************************************
% Ideal body weight
*********************************************************************************************************************************************************************
Adjusted weight
*********************************************************************************************************************************************************************
Usual body weight
*********************************************************************************************************************************************************************
% Usual body weight
*********************************************************************************************************************************************************************
59 kg
QUANTITY
*********************************************************************************************************************************************************************
166%
PERCENT
*********************************************************************************************************************************************************************
68.8 kg
QUANTITY
*********************************************************************************************************************************************************************
Diagnosis: facial fx
*********************************************************************************************************************************************************************
PMH
ORG
: breast ca, tongue ca, ovarian ca,
polymyalgia
GPE
,
NIDDM
ORG
, vertigo, hx
*********************************************************************************************************************************************************************
of falls
*********************************************************************************************************************************************************************
Food allergies and intolerances: none noted
*********************************************************************************************************************************************************************
Pertinent medications: RISS,
IV
GPE
abx, protonix, KCl (
30 mEq
CARDINAL
),
Dextrose
PERSON
*********************************************************************************************************************************************************************
5%
PERCENT
1/2 normal saline with KCl, others noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
206
*********************************************************************************************************************************************************************
[**
2181-6-5
DATE
**]
08:00 AM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
222
CARDINAL
*********************************************************************************************************************************************************************
[**
2181-6-4
DATE
**]
08:00 PM
TIME
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
11 mg/dL
*********************************************************************************************************************************************************************
[**
2181-6-4
DATE
**]
11:36 PM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
0.5 mg/dL
*********************************************************************************************************************************************************************
[**
2181-6-4
DATE
**]
11:36 PM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
134 mEq/L
*********************************************************************************************************************************************************************
[**
2181-6-4
DATE
**]
11:36 PM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
4.1 mEq/L
*********************************************************************************************************************************************************************
[**
2181-6-5
DATE
**]
09:13 AM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
98 mEq/L
*********************************************************************************************************************************************************************
[**
2181-6-4
DATE
**]
11:36 PM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
26 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2181-6-4
DATE
**]
11:36 PM
TIME
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
6.5
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2181-6-3
DATE
**]
12:30 AM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
8.5
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2181-6-4
DATE
**]
11:36 PM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
2.3 mg/dL
*********************************************************************************************************************************************************************
[**
2181-6-4
DATE
**]
11:36 PM
TIME
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
2.0
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2181-6-4
DATE
**]
11:36 PM
TIME
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
9.2 K/uL
*********************************************************************************************************************************************************************
[**
2181-6-5
DATE
**]
12:03 AM
TIME
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
10.9
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2181-6-5
DATE
**]
12:03 AM
TIME
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
32.7 %
PERCENT
*********************************************************************************************************************************************************************
[**
2181-6-5
DATE
**]
12:03 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support: NPO
*********************************************************************************************************************************************************************
GI
ORG
:
obese
NORP
, + bowel sounds
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
Obese
NORP
, At risk for malnutrition
*********************************************************************************************************************************************************************
Pt at risk due to:
NPO
ORG
/ hypocaloric diet, trauma
*********************************************************************************************************************************************************************
Estimated Nutritional Needs based on adjusted body wt
*********************************************************************************************************************************************************************
Calories:
1513-1720
DATE
(
22-25 cal/kg
TIME
)
*********************************************************************************************************************************************************************
Protein:
83
CARDINAL
-103 (
1.2-1.5
CARDINAL
g/kg)
*********************************************************************************************************************************************************************
Fluid: per team
*********************************************************************************************************************************************************************
Estimation of previous intake: unknown
*********************************************************************************************************************************************************************
Estimation of current intake: Inadequate d/t
NPO
ORG
status
*********************************************************************************************************************************************************************
Specifics:
78 year old
DATE
female admitted from outside hospital
S/P
ORG
fall
*********************************************************************************************************************************************************************
at home with multiple injuries including
Le Forte
FAC
fx, multiple sinus
*********************************************************************************************************************************************************************
fx
ORG
, orbital
fx
ORG
, facial and tongue swelling. Patient seen by SLP on [**
6
CARDINAL
-4**]
*********************************************************************************************************************************************************************
who recommended patient remain
NPO
ORG
. If patient
*********************************************************************************************************************************************************************
s diet cannot be
*********************************************************************************************************************************************************************
advanced consider initiating tube feedings to prevent further
*********************************************************************************************************************************************************************
nutritional decline.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
If diet cannot be advanced recommend starting tube feedings start with
*********************************************************************************************************************************************************************
Replete with Fiber @
15 ml
QUANTITY
/hr advance to goal of
65 ml
QUANTITY
/hr =
1560
DATE
*********************************************************************************************************************************************************************
kcals/97 g protein
*********************************************************************************************************************************************************************
Check residuals q
4-6 hours
TIME
hold if
greater than 150
CARDINAL
cc
*********************************************************************************************************************************************************************
Monitor lytes and glucose with initiation of tube feeding
*********************************************************************************************************************************************************************
Change to non-dextrose
IV
GPE
fluids once tube feedings started
*********************************************************************************************************************************************************************
Implement any SLP recs
*********************************************************************************************************************************************************************
Will continue to follow page [**Numeric
Identifier 1372
DATE
**] with questions
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
40461,Nutrition,"Subjective
CARDINAL
*********************************************************************************************************************************************************************
oriented x1
*********************************************************************************************************************************************************************
Objective
*********************************************************************************************************************************************************************
Height
*********************************************************************************************************************************************************************
Admit weight
*********************************************************************************************************************************************************************
Daily weight
*********************************************************************************************************************************************************************
Weight change
*********************************************************************************************************************************************************************
BMI
ORG
*********************************************************************************************************************************************************************
178 cm
QUANTITY
*********************************************************************************************************************************************************************
63 kg
QUANTITY
*********************************************************************************************************************************************************************
74.9 kg ([**
2113-2-3
DATE
**]
04:00 AM
TIME
)
*********************************************************************************************************************************************************************
19.9
*********************************************************************************************************************************************************************
Pertinent medications:
Ranitidine
PERSON
,
Multi
GPE
-vitamin,
ABX
ORG
,
Folic Acid
ORG
,
*********************************************************************************************************************************************************************
Thiamine
PERSON
,
Coumadin
PERSON
,
Lasix
PERSON
,
Colace
PERSON
(held), KCl (
20mEq
CARDINAL
repletion x2),
*********************************************************************************************************************************************************************
Magnesium sulfate (
2
CARDINAL
g repletion),
Heparin
NORP
drip
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
105
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
127
CARDINAL
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
12:00 PM
TIME
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
25 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
1.8 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
142 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
3.9 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
110 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
25 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(arterial)
*********************************************************************************************************************************************************************
65 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(venous)
*********************************************************************************************************************************************************************
48 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
PCO2 (arterial)
*********************************************************************************************************************************************************************
30 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
PCO2 (venous)
*********************************************************************************************************************************************************************
33 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
pH (arterial)
*********************************************************************************************************************************************************************
7.46
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
pH (venous)
*********************************************************************************************************************************************************************
7.43
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
5.5
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
07:16 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) arterial
*********************************************************************************************************************************************************************
22 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) venous
*********************************************************************************************************************************************************************
23 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
2.1
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
02:44 PM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
7.5
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
3.0 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Ionized Calcium
WORK_OF_ART
*********************************************************************************************************************************************************************
1.08
CARDINAL
mmol/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
11:46 AM
TIME
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
2.3 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
ALT
*********************************************************************************************************************************************************************
23 IU/L
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Alkaline Phosphate
ORG
*********************************************************************************************************************************************************************
51 IU/L
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
AST
*********************************************************************************************************************************************************************
24
IU/L
EVENT
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Amylase
*********************************************************************************************************************************************************************
40
IU/L
EVENT
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Total Bilirubin
PERSON
*********************************************************************************************************************************************************************
0.3
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Triglyceride
*********************************************************************************************************************************************************************
120 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-25
DATE
**] 03:36 AM
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
9.3
CARDINAL
K/uL
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
8.9
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
27.0 %
PERCENT
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support: Diet: NPO
*********************************************************************************************************************************************************************
Calorie counts: [**
2
CARDINAL
-1**] -
17 - 18
CARDINAL
*********************************************************************************************************************************************************************
GI
ORG
: soft, (+) bowel sounds; 500ml stool
today
DATE
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
Estimation of current intake: Inadequate
*********************************************************************************************************************************************************************
Specifics:
*********************************************************************************************************************************************************************
49 year old
DATE
male with mitral valve endocarditis, preop stroke
s/p MVR
ORG
*********************************************************************************************************************************************************************
(
29mm
QUANTITY
[**
First
ORDINAL
Name8 (NamePattern2) **] [**
First Name4
ORG
(NamePattern1)
1104
DATE
**] [**Last Name (NamePattern1)
1105
DATE
**]) debridement of aortic valve [**
1-27
CARDINAL
**]. Patient with
*********************************************************************************************************************************************************************
prolonged poor po
*********************************************************************************************************************************************************************
s during admit. Was on ground solids +
thin liquid
WORK_OF_ART
*********************************************************************************************************************************************************************
diet, refusing po
*********************************************************************************************************************************************************************
s at times. s/p calories counts
*********************************************************************************************************************************************************************
880
FAC
calories [**
2
CARDINAL
-1**]
*********************************************************************************************************************************************************************
and
270
CARDINAL
calories [**
2
CARDINAL
-2**]. Seen for video swallow evaluation this AM
*********************************************************************************************************************************************************************
SLP recommend
NPO
ORG
. Per discussion with PA
*********************************************************************************************************************************************************************
plan for
PEG
ORG
placement as
*********************************************************************************************************************************************************************
previously unable to place
NGT
ORG
and feel that patient will pull it out.
*********************************************************************************************************************************************************************
Agree with PEG for long term nutrition support to prevent further
*********************************************************************************************************************************************************************
nutritional decline and optimize nutrition for post-op healing. Noted
*********************************************************************************************************************************************************************
multiple lyte repletions.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
Current diet / nutrition support is appropriate: continue
*********************************************************************************************************************************************************************
NPO
ORG
per SLP recommendations
*********************************************************************************************************************************************************************
o SLP follow up when appropriate
*********************************************************************************************************************************************************************
Tube feeding recommendations: Agree with
PEG
ORG
*********************************************************************************************************************************************************************
o Once feeding tube placed, recommend begin
Isosource 1.5
ORG
@
*********************************************************************************************************************************************************************
20ml/hr, advance as tolerated to goal of
45ml
ORDINAL
/hr =
1620
DATE
calories and
*********************************************************************************************************************************************************************
73g protein
*********************************************************************************************************************************************************************
Check residuals, hold tube feed if greater than 200ml
*********************************************************************************************************************************************************************
Multivitamin / Mineral supplement: continue current
*********************************************************************************************************************************************************************
Check chemistry
10
CARDINAL
panel
daily
DATE
*********************************************************************************************************************************************************************
o Replete lytes
PRN
ORG
*********************************************************************************************************************************************************************
Will follow, page if questions *[**Numeric Identifier
606
CARDINAL
**]
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
40461,Nutrition,"Subjective
CARDINAL
*********************************************************************************************************************************************************************
Patient oob, tube feed running at
40 ml
QUANTITY
/hr.
*********************************************************************************************************************************************************************
Objective
*********************************************************************************************************************************************************************
Pertinent medications: noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
119
*********************************************************************************************************************************************************************
[**
2113-2-8
DATE
**]
08:00 AM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
150
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
10:00 PM
TIME
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
31 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-8
DATE
**]
02:50 AM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
2.0
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-8
DATE
**]
02:50 AM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
143 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-8
DATE
**]
02:50 AM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
3.4 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-8
DATE
**]
07:52 AM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
109 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-8
DATE
**]
02:50 AM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
25 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-8
DATE
**]
02:50 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(arterial)
*********************************************************************************************************************************************************************
65 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(venous)
*********************************************************************************************************************************************************************
48 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
PCO2 (arterial)
*********************************************************************************************************************************************************************
30 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
PCO2 (venous)
*********************************************************************************************************************************************************************
33 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
pH (arterial)
*********************************************************************************************************************************************************************
7.46
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
pH (venous)
*********************************************************************************************************************************************************************
7.43
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
05:19 PM
TIME
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
5.5
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
07:16 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) arterial
*********************************************************************************************************************************************************************
22 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) venous
*********************************************************************************************************************************************************************
23 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
2.2
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
7.8
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
4.0 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Ionized Calcium
WORK_OF_ART
*********************************************************************************************************************************************************************
1.07
CARDINAL
mmol/L
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
05:19 PM
TIME
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
2.1
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-8
DATE
**]
07:52 AM
TIME
*********************************************************************************************************************************************************************
ALT
*********************************************************************************************************************************************************************
21
IU/L
EVENT
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Alkaline Phosphate
ORG
*********************************************************************************************************************************************************************
50 IU/L
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
AST
*********************************************************************************************************************************************************************
23 IU/L
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Amylase
*********************************************************************************************************************************************************************
45
IU/L
EVENT
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Total Bilirubin
PERSON
*********************************************************************************************************************************************************************
0.4
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Triglyceride
*********************************************************************************************************************************************************************
120 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-25
DATE
**] 03:36 AM
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
10.1
CARDINAL
K/uL
*********************************************************************************************************************************************************************
[**
2113-2-8
DATE
**]
02:50 AM
TIME
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
8.3
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-2-8
DATE
**]
02:50 AM
TIME
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
26.1 %
PERCENT
*********************************************************************************************************************************************************************
[**
2113-2-8
DATE
**]
02:50 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support: Replete with fiber Full
*********************************************************************************************************************************************************************
strength;
*********************************************************************************************************************************************************************
Starting rate:
40 ml
QUANTITY
/hr;
Advance
PERSON
rate by
20 ml
QUANTITY
q6h Goal rate:
70 ml
QUANTITY
/hr
*********************************************************************************************************************************************************************
Residual Check: q4h Hold feeding for residual >= :
200 ml
QUANTITY
*********************************************************************************************************************************************************************
Flush w/
30 ml water q8h
QUANTITY
*********************************************************************************************************************************************************************
GI: Abdominal: Soft, Non-distended, Non-tender,
Bowel
PERSON
sounds present,
*********************************************************************************************************************************************************************
PEG site clean and dry.
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
49 year old
DATE
male
s/p PEG
ORG
placement
yesterday
DATE
, tube feed started
*********************************************************************************************************************************************************************
yesterday
DATE
, tolerated
Isosource 1.5
ORG
well, tube feed ordered changed to
*********************************************************************************************************************************************************************
Replete with fiber
this morning
TIME
, spoke to team, does not want patient
*********************************************************************************************************************************************************************
on special tube feed, recommend change to
Fibersource
ORG
HN as current
*********************************************************************************************************************************************************************
formula provides excess amount of protein. Noted discharge planning in
*********************************************************************************************************************************************************************
progress.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
Tube feeding: Fibersource HN goal 60ml/hr (
1728kcal/76
CARDINAL
g
*********************************************************************************************************************************************************************
protein)
*********************************************************************************************************************************************************************
Check chemistry
10
CARDINAL
panel daily, replete prn
*********************************************************************************************************************************************************************
Continue BS management
*********************************************************************************************************************************************************************
[**Numeric Identifier 943**] if has question
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
40461,Nutrition,"Subjective
CARDINAL
*********************************************************************************************************************************************************************
Patient asleep.
*********************************************************************************************************************************************************************
Objective
*********************************************************************************************************************************************************************
Height
*********************************************************************************************************************************************************************
Admit weight
*********************************************************************************************************************************************************************
Daily weight
*********************************************************************************************************************************************************************
Weight change
*********************************************************************************************************************************************************************
BMI
ORG
*********************************************************************************************************************************************************************
178 cm
QUANTITY
*********************************************************************************************************************************************************************
63 kg
QUANTITY
*********************************************************************************************************************************************************************
70.8 kg
QUANTITY
([**
2113-2-7
DATE
**]
04:00 AM
TIME
)
*********************************************************************************************************************************************************************
19.9
*********************************************************************************************************************************************************************
Pertinent medications:
Multiple Vitamins
PERSON
, Furosemide, Docusate Sodium,
*********************************************************************************************************************************************************************
others noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
157
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
04:00 AM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
158
CARDINAL
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
06:00 AM
TIME
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
33 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
04:00 AM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
1.9 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
04:00 AM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
145 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
04:00 AM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
3.7 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
04:00 AM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
111 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
04:00 AM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
24 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
04:00 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(arterial)
*********************************************************************************************************************************************************************
65 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(venous)
*********************************************************************************************************************************************************************
48 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
PCO2 (arterial)
*********************************************************************************************************************************************************************
30 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
PCO2 (venous)
*********************************************************************************************************************************************************************
33 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
pH (arterial)
*********************************************************************************************************************************************************************
7.46
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
pH (venous)
*********************************************************************************************************************************************************************
7.43
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
5.5
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
07:16 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) arterial
*********************************************************************************************************************************************************************
22 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) venous
*********************************************************************************************************************************************************************
23 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
2.2
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
7.8
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
4.0 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Ionized Calcium
WORK_OF_ART
*********************************************************************************************************************************************************************
1.08
CARDINAL
mmol/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
11:46 AM
TIME
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
2.0
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
11:00 PM
TIME
*********************************************************************************************************************************************************************
ALT
*********************************************************************************************************************************************************************
21
IU/L
EVENT
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Alkaline Phosphate
ORG
*********************************************************************************************************************************************************************
50 IU/L
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
AST
*********************************************************************************************************************************************************************
23 IU/L
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Amylase
*********************************************************************************************************************************************************************
45
IU/L
EVENT
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Total Bilirubin
PERSON
*********************************************************************************************************************************************************************
0.4
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**]
04:05 AM
TIME
*********************************************************************************************************************************************************************
Triglyceride
*********************************************************************************************************************************************************************
120 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-25
DATE
**] 03:36 AM
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
12.3 K/uL
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
04:00 AM
TIME
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
8.8
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
04:00 AM
TIME
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
26.9 %
PERCENT
*********************************************************************************************************************************************************************
[**
2113-2-7
DATE
**]
04:00 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support: Non-Standard TPN For Date:
*********************************************************************************************************************************************************************
[**
2113-2-6
DATE
**] (1600ml,
270drextrose/80protein/35fat
CARDINAL
)
*********************************************************************************************************************************************************************
Replete with fiber Full strength;
*********************************************************************************************************************************************************************
Starting rate:
10 ml
QUANTITY
/hr;
Advance
PERSON
rate by
10 ml q6h Goal
QUANTITY
rate:
60 ml
QUANTITY
/hr
*********************************************************************************************************************************************************************
Residual Check: q4h Hold feeding for residual >= :
200 ml
QUANTITY
*********************************************************************************************************************************************************************
Flush w/
30 ml water q8h
QUANTITY
*********************************************************************************************************************************************************************
GI: Abdominal: Soft, Non-distended, Non-tender,
Bowel
PERSON
sounds present,
*********************************************************************************************************************************************************************
PEG site clean and dry.
Peg
PERSON
to gravity drainage
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
49 year old
DATE
male with
Mitral
NORP
valve endocarditis, preop stroke
s/p MVR
ORG
*********************************************************************************************************************************************************************
and debridement of aortic valve [**
1-27
CARDINAL
**], patient failed
S & S
ORG
evaluation,
*********************************************************************************************************************************************************************
TPN
ORG
started over
the weekend
DATE
while awaiting
PEG
PERSON
.
PEG
PERSON
placed
*********************************************************************************************************************************************************************
yesterday
DATE
, plan to start tube feeds
today
DATE
, current tube feed order not
*********************************************************************************************************************************************************************
meeting patient
*********************************************************************************************************************************************************************
s estimated need. Noted patient with post op fluid
*********************************************************************************************************************************************************************
gain, recommend fluid restricted formula.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
Consider ordering day
1 TPN
QUANTITY
tonight
TIME
while slowly advancing
*********************************************************************************************************************************************************************
tube feed
*********************************************************************************************************************************************************************
Tube feeding:
Isosource 1.5cal
ORG
goal 45ml/hr (
1620kcal/73
CARDINAL
g
*********************************************************************************************************************************************************************
protein)
*********************************************************************************************************************************************************************
Start tube feed at
15ml
ORDINAL
/hr and adv slowly as tol
*********************************************************************************************************************************************************************
Check chemistry
10
CARDINAL
panel daily, replete prn
*********************************************************************************************************************************************************************
Continue BS management
*********************************************************************************************************************************************************************
[**Numeric Identifier 943**] if has question
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
40461,Nutrition,"Subjective
CARDINAL
*********************************************************************************************************************************************************************
patient sleeping
*********************************************************************************************************************************************************************
Objective
*********************************************************************************************************************************************************************
Height
*********************************************************************************************************************************************************************
Admit weight
*********************************************************************************************************************************************************************
Daily weight
*********************************************************************************************************************************************************************
Weight change
*********************************************************************************************************************************************************************
BMI
ORG
*********************************************************************************************************************************************************************
178 cm
QUANTITY
*********************************************************************************************************************************************************************
63 kg
QUANTITY
*********************************************************************************************************************************************************************
74.9 kg ([**
2113-2-3
DATE
**]
04:00 AM
TIME
)
*********************************************************************************************************************************************************************
19.9
*********************************************************************************************************************************************************************
Pertinent medications:
D5
PRODUCT
@10 ml/hr, KCl (
40 mEq
CARDINAL
repletion), RISS,
IV
GPE
*********************************************************************************************************************************************************************
abx, lansoprazole, famotidine, others noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
73
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
12:00 PM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
135
CARDINAL
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
12:00 AM
TIME
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
25 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
03:42 AM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
1.6 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
03:42 AM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
140 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
03:42 AM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
3.5 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
03:42 AM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
108 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
03:42 AM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
22 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
03:42 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(arterial)
*********************************************************************************************************************************************************************
65 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(venous)
*********************************************************************************************************************************************************************
48 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
PCO2 (arterial)
*********************************************************************************************************************************************************************
30 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
PCO2 (venous)
*********************************************************************************************************************************************************************
33 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
pH (arterial)
*********************************************************************************************************************************************************************
7.46
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
pH (venous)
*********************************************************************************************************************************************************************
7.43
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
5.5
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
07:16 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) arterial
*********************************************************************************************************************************************************************
22 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) venous
*********************************************************************************************************************************************************************
23 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
2.1
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
02:44 PM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
7.3
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
03:42 AM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
3.1
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
03:42 AM
TIME
*********************************************************************************************************************************************************************
Ionized Calcium
WORK_OF_ART
*********************************************************************************************************************************************************************
1.08
CARDINAL
mmol/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
11:46 AM
TIME
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
2.0
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
03:42 AM
TIME
*********************************************************************************************************************************************************************
ALT
*********************************************************************************************************************************************************************
23 IU/L
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Alkaline Phosphate
ORG
*********************************************************************************************************************************************************************
51 IU/L
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
AST
*********************************************************************************************************************************************************************
24
IU/L
EVENT
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Amylase
*********************************************************************************************************************************************************************
40
IU/L
EVENT
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Total Bilirubin
PERSON
*********************************************************************************************************************************************************************
0.3
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-3
DATE
**]
05:24 AM
TIME
*********************************************************************************************************************************************************************
Triglyceride
*********************************************************************************************************************************************************************
120 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-25
DATE
**] 03:36 AM
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
13.4 K/uL
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
03:42 AM
TIME
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
9.8
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
03:42 AM
TIME
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
29.7 %
PERCENT
*********************************************************************************************************************************************************************
[**
2113-2-4
DATE
**]
03:42 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support: NPO
*********************************************************************************************************************************************************************
GI
ORG
: soft, hypoactive bowel sounds
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
Specifics: Patient s/p video swallow [**
2
CARDINAL
-3**] which recommended patient be
*********************************************************************************************************************************************************************
NPO
ORG
. Received consult for
PPN
ORG
recommendations. Per discussion with
PA
ORG
,
*********************************************************************************************************************************************************************
plan is for
PEG
ORG
placement on
Monday
DATE
and to supplement nutrition with
*********************************************************************************************************************************************************************
parenteral nutrition until
PEG
ORG
is able to be used. Patient with PICC,
*********************************************************************************************************************************************************************
Day 1 TPN ordered to start
tonight
TIME
.
NGT
ORG
was attempted earlier in week
*********************************************************************************************************************************************************************
and was unable to placed and team thinks patient would pull it out.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
1. Day 1 TPN tonight
*********************************************************************************************************************************************************************
2. Pending glycemic control advance to goal
TPN
ORG
1.6L (
270
CARDINAL
g
*********************************************************************************************************************************************************************
dextrose/80 g amino acids/35 g lipids)=
1588
DATE
kcals
*********************************************************************************************************************************************************************
3
CARDINAL
. Check TG hold lipids if greater than
400
CARDINAL
*********************************************************************************************************************************************************************
4. Once PEG placed start with
Isosource HN @
ORG
15 ml
QUANTITY
/hr advance to
*********************************************************************************************************************************************************************
goal of
45 ml
QUANTITY
/hr =
1620
DATE
kcals/
73
CARDINAL
g protein
*********************************************************************************************************************************************************************
5. Will follow page [**Numeric
Identifier 1372
DATE
**] with questions
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
40461,Nutrition,"Subjective
CARDINAL
*********************************************************************************************************************************************************************
Patient asleep, [**Name8 (
MD
GPE
) 77**] RN, patient refused all po food or supplements.
*********************************************************************************************************************************************************************
Objective
*********************************************************************************************************************************************************************
Height
*********************************************************************************************************************************************************************
Admit weight
*********************************************************************************************************************************************************************
Daily weight
*********************************************************************************************************************************************************************
Weight change
*********************************************************************************************************************************************************************
BMI
ORG
*********************************************************************************************************************************************************************
178 cm
QUANTITY
*********************************************************************************************************************************************************************
63 kg
QUANTITY
*********************************************************************************************************************************************************************
70.5 kg
QUANTITY
([**
2113-1-19
DATE
**]
08:00 AM
TIME
)
*********************************************************************************************************************************************************************
up due to fluid
*********************************************************************************************************************************************************************
19.9
*********************************************************************************************************************************************************************
Ideal body weight
*********************************************************************************************************************************************************************
% Ideal body weight
*********************************************************************************************************************************************************************
Adjusted weight
*********************************************************************************************************************************************************************
Usual body weight
*********************************************************************************************************************************************************************
% Usual body weight
*********************************************************************************************************************************************************************
75.3 kg
QUANTITY
*********************************************************************************************************************************************************************
119%
PERCENT
*********************************************************************************************************************************************************************
63 kg
QUANTITY
*********************************************************************************************************************************************************************
100%
*********************************************************************************************************************************************************************
Diagnosis: MITRAL VALVE ENDOCARDITIS
*********************************************************************************************************************************************************************
PMHx: None - no medical care x
30 years
DATE
*********************************************************************************************************************************************************************
Food allergies and intolerances: not available
*********************************************************************************************************************************************************************
Pertinent medications: Furosemide , Milrinone, Multivitamins,
Thiamine
ORG
,
*********************************************************************************************************************************************************************
FoLIC Acid,
Nicotine Patch
NORP
, Heparin, Docusate Sodium ,
Nafcillin
GPE
,
*********************************************************************************************************************************************************************
Potassium Chloride, others noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
117 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
25 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
1.5 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
137 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
3.3 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
103 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
22 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
PO2
PERSON
(venous)
*********************************************************************************************************************************************************************
145 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-15
DATE
**]
04:51 PM
TIME
*********************************************************************************************************************************************************************
PCO2 (venous)
*********************************************************************************************************************************************************************
34 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-15
DATE
**]
04:51 PM
TIME
*********************************************************************************************************************************************************************
pH (venous)
*********************************************************************************************************************************************************************
7.45
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-15
DATE
**]
04:51 PM
TIME
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
5.0
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-18
DATE
**]
12:03 PM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) venous
*********************************************************************************************************************************************************************
24 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-15
DATE
**]
04:51 PM
TIME
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
1.9
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-1-18
DATE
**]
07:15 AM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
7.1 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
4.8 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
1.9 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
ALT
*********************************************************************************************************************************************************************
36 IU/L
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Alkaline Phosphate
ORG
*********************************************************************************************************************************************************************
44 IU/L
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
AST
*********************************************************************************************************************************************************************
54
IU/L
EVENT
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Total Bilirubin
PERSON
*********************************************************************************************************************************************************************
0.4
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
13.0 K/uL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
11.8
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
35.2 %
PERCENT
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Current diet order / nutrition support: Regular; Supplement: Ensure
*********************************************************************************************************************************************************************
Plus breakfast, lunch, dinner
*********************************************************************************************************************************************************************
GI: Abdominal: Soft, Non-tender,
Bowel
PERSON
sounds present
*********************************************************************************************************************************************************************
Extremities: Right lower extremity edema: Absent, Left lower extremity
*********************************************************************************************************************************************************************
edema
*********************************************************************************************************************************************************************
Skin: Warm, Rash: upper and lower ext, occ petechiae
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
At risk for malnutrition
*********************************************************************************************************************************************************************
Patient at risk due to: Low po intake, current illness, head
CT
ORG
showed multipl
*********************************************************************************************************************************************************************
e small non-hemorrhagic
*********************************************************************************************************************************************************************
infarcts suspicious for septic emboli,
*********************************************************************************************************************************************************************
Estimated Nutritional Needs
*********************************************************************************************************************************************************************
Calories:
1575-1764
DATE
(
BEE
ORG
x or / 25-28 cal/kg)
*********************************************************************************************************************************************************************
Protein:
76-88
CARDINAL
(
1.2-1.4
CARDINAL
g/kg)
*********************************************************************************************************************************************************************
Fluid: per team
*********************************************************************************************************************************************************************
Calculations based on: Admit weight
*********************************************************************************************************************************************************************
Estimation of previous intake: Inadequate
*********************************************************************************************************************************************************************
Estimation of current intake: Inadequate
*********************************************************************************************************************************************************************
Specifics:
*********************************************************************************************************************************************************************
49 year old
DATE
male found to have staphylococcus aureus bacterial
*********************************************************************************************************************************************************************
endocarditis with severe mitral regurgitation [**
3
CARDINAL
-21**] mitral valve
*********************************************************************************************************************************************************************
vegetations and flail leaflet. Patient transferred from [**Hospital **] [**Hospital1
5
CARDINAL
**] for
CT
ORG
surgery evaluation and further management.
*********************************************************************************************************************************************************************
Patient s/p speech and swallow evaluation, okay to have regular diet,
*********************************************************************************************************************************************************************
yet patient refused to take pos. spoke to team
this morning
TIME
, team
*********************************************************************************************************************************************************************
considering
NGT
ORG
placement.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
Po as tolerance
*********************************************************************************************************************************************************************
Tube feeding recommendations:
Nutren Pulmonary
PERSON
goal
45ml
ORDINAL
/hr
*********************************************************************************************************************************************************************
(
1620kcal/73.4
CARDINAL
g protein)
*********************************************************************************************************************************************************************
Monitor tube feed tolerance
*********************************************************************************************************************************************************************
Check chemistry
10
CARDINAL
panel daily, replete as you are doing
*********************************************************************************************************************************************************************
Consider adding phos binder if serum phos remains elevated
*********************************************************************************************************************************************************************
Start regular insulin sliding scale if serum glucose greater
*********************************************************************************************************************************************************************
than 150 mg/dL
*********************************************************************************************************************************************************************
Other: [**Numeric Identifier 943**] if has question
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
40461,Nutrition,"Subjective
CARDINAL
*********************************************************************************************************************************************************************
Patient asleep, [**Name8 (
MD
GPE
) 77**] RN, patient refused all po food or supplements.
*********************************************************************************************************************************************************************
Objective
*********************************************************************************************************************************************************************
Height
*********************************************************************************************************************************************************************
Admit weight
*********************************************************************************************************************************************************************
Daily weight
*********************************************************************************************************************************************************************
Weight change
*********************************************************************************************************************************************************************
BMI
ORG
*********************************************************************************************************************************************************************
178 cm
QUANTITY
*********************************************************************************************************************************************************************
63 kg
QUANTITY
*********************************************************************************************************************************************************************
70.5 kg
QUANTITY
([**
2113-1-19
DATE
**]
08:00 AM
TIME
)
*********************************************************************************************************************************************************************
up due to fluid
*********************************************************************************************************************************************************************
19.9
*********************************************************************************************************************************************************************
Ideal body weight
*********************************************************************************************************************************************************************
% Ideal body weight
*********************************************************************************************************************************************************************
Adjusted weight
*********************************************************************************************************************************************************************
Usual body weight
*********************************************************************************************************************************************************************
% Usual body weight
*********************************************************************************************************************************************************************
75.3 kg
QUANTITY
*********************************************************************************************************************************************************************
119%
PERCENT
*********************************************************************************************************************************************************************
63 kg
QUANTITY
*********************************************************************************************************************************************************************
100%
*********************************************************************************************************************************************************************
Diagnosis: MITRAL VALVE ENDOCARDITIS
*********************************************************************************************************************************************************************
PMHx: None - no medical care x
30 years
DATE
*********************************************************************************************************************************************************************
Food allergies and intolerances: not available
*********************************************************************************************************************************************************************
Pertinent medications: Furosemide , Milrinone, Multivitamins,
Thiamine
ORG
,
*********************************************************************************************************************************************************************
FoLIC Acid,
Nicotine Patch
NORP
, Heparin, Docusate Sodium ,
Nafcillin
GPE
,
*********************************************************************************************************************************************************************
Potassium Chloride, others noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
117 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
25 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
1.5 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
137 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
3.3 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
103 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
22 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
PO2
PERSON
(venous)
*********************************************************************************************************************************************************************
145 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-15
DATE
**]
04:51 PM
TIME
*********************************************************************************************************************************************************************
PCO2 (venous)
*********************************************************************************************************************************************************************
34 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-15
DATE
**]
04:51 PM
TIME
*********************************************************************************************************************************************************************
pH (venous)
*********************************************************************************************************************************************************************
7.45
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-15
DATE
**]
04:51 PM
TIME
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
5.0
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-18
DATE
**]
12:03 PM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) venous
*********************************************************************************************************************************************************************
24 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-15
DATE
**]
04:51 PM
TIME
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
1.9
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-1-18
DATE
**]
07:15 AM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
7.1 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
4.8 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-20
DATE
**] 02:36 AM
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
IOPub message rate exceeded. The Jupyter server will temporarily stop sending output to the client in order to avoid crashing it. To change this limit, set the config variable `--ServerApp.iopub_msg_rate_limit`. Current values: ServerApp.iopub_msg_rate_limit=1000.0 (msgs/sec) ServerApp.rate_limit_window=3.0 (secs)
*********************************************************************************************************************************************************************
3
CARDINAL
. Will follow page [**Numeric
Identifier 1372
DATE
**] with questions
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
40461,Nutrition,"Subjective
CARDINAL
*********************************************************************************************************************************************************************
oriented x
1
CARDINAL
*********************************************************************************************************************************************************************
Objective
*********************************************************************************************************************************************************************
Height
*********************************************************************************************************************************************************************
Admit weight
*********************************************************************************************************************************************************************
Daily weight
*********************************************************************************************************************************************************************
Weight change
*********************************************************************************************************************************************************************
BMI
ORG
*********************************************************************************************************************************************************************
178 cm
QUANTITY
*********************************************************************************************************************************************************************
63 kg
QUANTITY
*********************************************************************************************************************************************************************
72 kg
QUANTITY
([**
2113-2-1
DATE
**]
04:00 AM
TIME
)
*********************************************************************************************************************************************************************
19.9
*********************************************************************************************************************************************************************
Pertinent medications:
Ranitidine
PERSON
,
ABX
ORG
,
Folic Acid
ORG
,
Thiamine
ORG
,
*********************************************************************************************************************************************************************
Multi
GPE
-vitamin, lasix,
Colace
PERSON
(Held), KCl (
20mEq
CARDINAL
repletion x3)
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
108 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
124
CARDINAL
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
12:00 AM
TIME
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
28 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
2.0
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
139 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
3.7 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
105 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
23 mEq/L
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(arterial)
*********************************************************************************************************************************************************************
65 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(venous)
*********************************************************************************************************************************************************************
48 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
PCO2 (arterial)
*********************************************************************************************************************************************************************
30 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
PCO2 (venous)
*********************************************************************************************************************************************************************
33 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
pH (arterial)
*********************************************************************************************************************************************************************
7.46
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
pH (venous)
*********************************************************************************************************************************************************************
7.43
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
5.5
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
07:16 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) arterial
*********************************************************************************************************************************************************************
22 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-31
DATE
**]
04:47 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) venous
*********************************************************************************************************************************************************************
23 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
2.2
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
7.6 mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
4.6
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
Ionized Calcium
WORK_OF_ART
*********************************************************************************************************************************************************************
1.08
CARDINAL
mmol/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
11:46 AM
TIME
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
2.2
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
ALT
*********************************************************************************************************************************************************************
20 IU/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Alkaline Phosphate
ORG
*********************************************************************************************************************************************************************
57 IU/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
AST
*********************************************************************************************************************************************************************
26 IU/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Amylase
*********************************************************************************************************************************************************************
17 IU/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Total Bilirubin
PERSON
*********************************************************************************************************************************************************************
0.4
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Triglyceride
*********************************************************************************************************************************************************************
120 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-25
DATE
**] 03:36 AM
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
18.2 K/uL
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
10.4
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
31.5 %
PERCENT
*********************************************************************************************************************************************************************
[**
2113-2-1
DATE
**]
03:30 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support: Diet: Ground solids, thin
*********************************************************************************************************************************************************************
liquids; Ensure Pudding and Carnation Instant Breakfast with meals;
*********************************************************************************************************************************************************************
calorie counts [**
2
CARDINAL
-1**], [**
2
CARDINAL
-2**], [**
2
CARDINAL
-3**]
*********************************************************************************************************************************************************************
GI
ORG
: soft, (+) bowel sounds; green liquid stool
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
Estimation of current intake: Inadequate
*********************************************************************************************************************************************************************
Specifics:
*********************************************************************************************************************************************************************
Patient
s/p MVR
ORG
/ AVR [**
1-27
CARDINAL
**]. Extubated [**
1-30
CARDINAL
**]. Seen by SLP [**
1-31
CARDINAL
**] who
*********************************************************************************************************************************************************************
recommended above altered consistency diet with
1:1
CARDINAL
supervision. [**Name8 (
MD
GPE
) **]
*********************************************************************************************************************************************************************
RN
ORG
, patient took Ensure pudding and some Carnation Instant Breakfast
*********************************************************************************************************************************************************************
shake this AM with a lot of encouragement. Patient takes very small
*********************************************************************************************************************************************************************
bites and is a picky eater.
RN
ORG
reports wife to bring in a list of
*********************************************************************************************************************************************************************
foods that patient likes.
Calorie
PERSON
counts starting
today
DATE
. Concerned
*********************************************************************************************************************************************************************
with nutrition status given poor po
*********************************************************************************************************************************************************************
s during admit (refusing po
*********************************************************************************************************************************************************************
s at
*********************************************************************************************************************************************************************
times), only received tube feed briefly on/off and recent surgery.
*********************************************************************************************************************************************************************
Would strongly recommend supplemental tube feed to optimize nutrition
*********************************************************************************************************************************************************************
for post-op recovery.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
Current diet / nutrition support is appropriate:
*********************************************************************************************************************************************************************
Encourage/assist with po
*********************************************************************************************************************************************************************
o Encourage wife to bring in food preference list or food
*********************************************************************************************************************************************************************
o Calorie counts
*********************************************************************************************************************************************************************
please record on kitchen receipt percent
*********************************************************************************************************************************************************************
eaten
*********************************************************************************************************************************************************************
Oral supplements: Continue as ordered
*********************************************************************************************************************************************************************
Multivitamin / Mineral supplement: continue current
*********************************************************************************************************************************************************************
Tube feeding recommendations:
*********************************************************************************************************************************************************************
o Consider placing
NGT
ORG
and beginning tube feeds to supplement
*********************************************************************************************************************************************************************
poor po
*********************************************************************************************************************************************************************
o Tube feed goal would be:
Nutren Pulmonary @
PERSON
45ml/hr =
1620
DATE
*********************************************************************************************************************************************************************
calories and
73
CARDINAL
g protein
*********************************************************************************************************************************************************************
Check chemistry
10
CARDINAL
panel
daily
DATE
*********************************************************************************************************************************************************************
Will follow, page if questions *[**Numeric Identifier
606
CARDINAL
**]
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
40461,Nutrition,"Subjective
CARDINAL
*********************************************************************************************************************************************************************
just extubated
*********************************************************************************************************************************************************************
Objective
*********************************************************************************************************************************************************************
Height
*********************************************************************************************************************************************************************
Admit weight
*********************************************************************************************************************************************************************
Daily weight
*********************************************************************************************************************************************************************
Weight change
*********************************************************************************************************************************************************************
BMI
ORG
*********************************************************************************************************************************************************************
178 cm
QUANTITY
*********************************************************************************************************************************************************************
63 kg
QUANTITY
*********************************************************************************************************************************************************************
76.2 kg ([**
2113-1-30
DATE
**]
04:00 AM
TIME
)
*********************************************************************************************************************************************************************
19.9
*********************************************************************************************************************************************************************
Pertinent medications: Multivitamins, others noted
*********************************************************************************************************************************************************************
Labs:
*********************************************************************************************************************************************************************
Value
*********************************************************************************************************************************************************************
Date
*********************************************************************************************************************************************************************
Glucose
*********************************************************************************************************************************************************************
106 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
07:59 AM
TIME
*********************************************************************************************************************************************************************
Glucose Finger
Stick
FAC
*********************************************************************************************************************************************************************
93
*********************************************************************************************************************************************************************
[**
2113-1-29
DATE
**]
06:00 PM
TIME
*********************************************************************************************************************************************************************
BUN
ORG
*********************************************************************************************************************************************************************
20 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Creatinine
*********************************************************************************************************************************************************************
1.6 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Sodium
*********************************************************************************************************************************************************************
137 mEq
CARDINAL
/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Potassium
*********************************************************************************************************************************************************************
3.5 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Chloride
*********************************************************************************************************************************************************************
104 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
TCO2
*********************************************************************************************************************************************************************
22 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(arterial)
*********************************************************************************************************************************************************************
85.[**Numeric Identifier 299**] mm Hg
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
09:19 AM
TIME
*********************************************************************************************************************************************************************
PO2
PERSON
(venous)
*********************************************************************************************************************************************************************
48 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
PCO2 (arterial)
*********************************************************************************************************************************************************************
33 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
09:19 AM
TIME
*********************************************************************************************************************************************************************
PCO2 (venous)
*********************************************************************************************************************************************************************
33 mm
QUANTITY
Hg
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
pH (arterial)
*********************************************************************************************************************************************************************
7.41
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
09:19 AM
TIME
*********************************************************************************************************************************************************************
pH (venous)
*********************************************************************************************************************************************************************
7.43
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
pH (urine)
*********************************************************************************************************************************************************************
5.0
CARDINAL
units
*********************************************************************************************************************************************************************
[**
2113-1-25
DATE
**]
02:26 PM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) arterial
*********************************************************************************************************************************************************************
22 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
09:19 AM
TIME
*********************************************************************************************************************************************************************
CO2 (
Calc
PERSON
) venous
*********************************************************************************************************************************************************************
23 mEq/L
*********************************************************************************************************************************************************************
[**
2113-1-21
DATE
**]
05:21 PM
TIME
*********************************************************************************************************************************************************************
Albumin
*********************************************************************************************************************************************************************
2.2
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Calcium non-ionized
*********************************************************************************************************************************************************************
8.4 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Phosphorus
*********************************************************************************************************************************************************************
5.2
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Ionized Calcium
WORK_OF_ART
*********************************************************************************************************************************************************************
1.09 mmol/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
07:59 AM
TIME
*********************************************************************************************************************************************************************
Magnesium
*********************************************************************************************************************************************************************
2.1
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
ALT
*********************************************************************************************************************************************************************
20 IU/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Alkaline Phosphate
ORG
*********************************************************************************************************************************************************************
57 IU/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
AST
*********************************************************************************************************************************************************************
26 IU/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Amylase
*********************************************************************************************************************************************************************
17 IU/L
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Total Bilirubin
PERSON
*********************************************************************************************************************************************************************
0.4
CARDINAL
mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Triglyceride
*********************************************************************************************************************************************************************
120 mg/dL
*********************************************************************************************************************************************************************
[**
2113-1-25
DATE
**] 03:36 AM
*********************************************************************************************************************************************************************
WBC
ORG
*********************************************************************************************************************************************************************
11.5
CARDINAL
K/uL
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Hgb
*********************************************************************************************************************************************************************
10.3
CARDINAL
g/dL
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Hematocrit
PRODUCT
*********************************************************************************************************************************************************************
30.1 %
PERCENT
*********************************************************************************************************************************************************************
[**
2113-1-30
DATE
**]
03:25 AM
TIME
*********************************************************************************************************************************************************************
Current diet order / nutrition support:
Nutren Pulmonary Full
PERSON
strength;
*********************************************************************************************************************************************************************
Starting rate:
10 ml
QUANTITY
/hr;
Advance
PERSON
rate by
10 ml q4h Goal
QUANTITY
rate:
50 ml
QUANTITY
/hr
*********************************************************************************************************************************************************************
Residual Check: q4h Hold feeding for residual >= :
200 ml
QUANTITY
*********************************************************************************************************************************************************************
Flush w/
30 ml water q4h
QUANTITY
( not running)
*********************************************************************************************************************************************************************
GI
ORG
: soft, flesiseal in place
*********************************************************************************************************************************************************************
SKIN: stage
2
CARDINAL
wounds
*********************************************************************************************************************************************************************
Assessment of Nutritional Status
*********************************************************************************************************************************************************************
49 year old
DATE
male admitted on [**
1-15
CARDINAL
**] with endocarditis
s/p MVR
ORG
and aortic
*********************************************************************************************************************************************************************
valve debridement on [**
1-27
CARDINAL
**], patient extubated
this morning
TIME
. Patient
*********************************************************************************************************************************************************************
well known to me from
CCU
ORG
, patient with minimal nutrition since
*********************************************************************************************************************************************************************
hospital admission (previously refused po food and nutrition
*********************************************************************************************************************************************************************
supplements in the ccu, received
1 day
DATE
of tube feed prior to OR.
*********************************************************************************************************************************************************************
Patient at very high risk for malnutrition, highly recommend replace
*********************************************************************************************************************************************************************
feeding tube, restart tube feed as temporary nutrition support for post
*********************************************************************************************************************************************************************
op recovery.
*********************************************************************************************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*********************************************************************************************************************************************************************
Adv diet if remains medically stable
*********************************************************************************************************************************************************************
Continue tube feed as supplemental nutrition support: goal
*********************************************************************************************************************************************************************
Nutren Pulmonary
PERSON
goal
45ml
ORDINAL
/hr to provide 1620kcal/73.4g protein
*********************************************************************************************************************************************************************
Phos binder if serum phos remains elevated
*********************************************************************************************************************************************************************
Check chemistry
10
CARDINAL
panel daily, replete prn
*********************************************************************************************************************************************************************
BS management
*********************************************************************************************************************************************************************
Other: [**Numeric Identifier 943**]
*********************************************************************************************************************************************************************
"
*********************************************************************************************************************************************************************
Analysis with SciSpacy¶
In [39]:
import scispacy
import spacy
In [40]:
# nlp = spacy.load('en_core_web_sm')
notes = []
with open('ICD9-E8881_Patients_NutritionNotes.csv', 'r') as fin:
lines = fin.readlines()
for line in lines:
notes.append(line)
print(notes)
print(len(notes))
['SUBJECT_ID,CATEGORY,TEXT\n', '17610,Nutrition,"Patient transferred to MICU for concern for aspiration. Diet changed\n', ' to NPO; NGT in for medication. Noted plan to transition to comfort\n', ' focused care.\n', ' Will sign off at this time. Please consult if needed. Pager *[**Numeric Identifier 5307**]\n', '"\n', '40493,Nutrition,"Objective\n', ' Pertinent medications: RISS, SS lytes, thiamin, folate, lasix, bowel\n', ' regimen, MOM, reglan, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 93 mg/dL\n', ' [**2172-11-9**] 01:50 AM\n', ' Glucose Finger Stick\n', ' 120\n', ' [**2172-11-9**] 08:57 AM\n', ' BUN\n', ' 15 mg/dL\n', ' [**2172-11-9**] 01:50 AM\n', ' Creatinine\n', ' 0.6 mg/dL\n', ' [**2172-11-9**] 01:50 AM\n', ' Sodium\n', ' 137 mEq/L\n', ' [**2172-11-9**] 01:50 AM\n', ' Potassium\n', ' 3.9 mEq/L\n', ' [**2172-11-9**] 01:50 AM\n', ' Chloride\n', ' 106 mEq/L\n', ' [**2172-11-9**] 01:50 AM\n', ' TCO2\n', ' 24 mEq/L\n', ' [**2172-11-9**] 01:50 AM\n', ' PO2 (arterial)\n', ' 66 mm Hg\n', ' [**2172-11-9**] 08:57 AM\n', ' PCO2 (arterial)\n', ' 41 mm Hg\n', ' [**2172-11-9**] 08:57 AM\n', ' pH (arterial)\n', ' 7.42 units\n', ' [**2172-11-9**] 08:57 AM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2172-11-1**] 06:06 PM\n', ' CO2 (Calc) arterial\n', ' 28 mEq/L\n', ' [**2172-11-9**] 08:57 AM\n', ' Albumin\n', ' 2.6 g/dL\n', ' [**2172-11-3**] 02:24 AM\n', ' Calcium non-ionized\n', ' 8.7 mg/dL\n', ' [**2172-11-9**] 01:50 AM\n', ' Phosphorus\n', ' 4.5 mg/dL\n', ' [**2172-11-9**] 01:50 AM\n', ' Ionized Calcium\n', ' 1.11 mmol/L\n', ' [**2172-11-5**] 01:34 PM\n', ' Magnesium\n', ' 2.2 mg/dL\n', ' [**2172-11-9**] 01:50 AM\n', ' Current diet order / nutrition support: Fibersource HN@60mL/hr (1728\n', ' kcals/73 gr aa) not infusing\n', ' GI: Abd soft/+bs\n', ' Assessment of Nutritional Status\n', ' Specifics:\n', ' Pt extubated earlier today. Pt was previously tolerating TF\n', 's @ goal,\n', ' meeting 100% estimated nutrition needs. Anticipate diet advancement as\n', ' able.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Advance diet per team c/ swallow eval if pt shows s/s of aspiration and\n', " advance diet per SLP- vs place NGT and resume TF's if unable to take\n", ' po\n', " Will follow plan -please page c/ ?'s #[**Numeric Identifier 1684**]\n", '"\n', '40493,Nutrition,"Subjective\n', ' intubated\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 168 cm\n', ' 65 kg\n', ' 23.1\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 64.4 kg\n', ' 101%\n', ' Diagnosis: S/P Fall\n', ' PMH : etoh, smoker, cirrhosis\n', ' Food allergies and intolerances: NKFA\n', ' Pertinent medications: fentanyl, LR @ 10 ml/hr, lasix, versed, RISS, IV\n', ' abx, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 155 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Glucose Finger Stick\n', ' 151\n', ' [**2172-11-2**] 08:00 AM\n', ' BUN\n', ' 17 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Creatinine\n', ' 0.8 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Sodium\n', ' 146 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' Potassium\n', ' 3.6 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' Chloride\n', ' 111 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' TCO2\n', ' 29 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' PO2 (arterial)\n', ' 113 mm Hg\n', ' [**2172-11-2**] 11:55 AM\n', ' PCO2 (arterial)\n', ' 41 mm Hg\n', ' [**2172-11-2**] 11:55 AM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2172-11-2**] 11:55 AM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2172-11-1**] 06:06 PM\n', ' CO2 (Calc) arterial\n', ' 30 mEq/L\n', ' [**2172-11-2**] 11:55 AM\n', ' Albumin\n', ' 3.0 g/dL\n', ' [**2172-10-31**] 02:55 AM\n', ' Calcium non-ionized\n', ' 8.1 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Phosphorus\n', ' 2.5 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Ionized Calcium\n', ' 1.16 mmol/L\n', ' [**2172-11-2**] 11:55 AM\n', ' Magnesium\n', ' 1.7 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' ALT\n', ' 14 IU/L\n', ' [**2172-10-31**] 02:55 AM\n', ' Alkaline Phosphate\n', ' 73 IU/L\n', ' [**2172-10-31**] 02:55 AM\n', ' AST\n', ' 43 IU/L\n', ' [**2172-10-31**] 02:55 AM\n', ' Total Bilirubin\n', ' 3.4 mg/dL\n', ' [**2172-10-31**] 02:55 AM\n', ' WBC\n', ' 23.2 K/uL\n', ' [**2172-11-2**] 01:06 AM\n', ' Hgb\n', ' 9.1 g/dL\n', ' [**2172-11-2**] 01:06 AM\n', ' Hematocrit\n', ' 27.2 %\n', ' [**2172-11-2**] 01:06 AM\n', ' Current diet order / nutrition support: NPO replete with fiber @ 60\n', ' ml/hr\n', ' GI: OGT\n', ' Assessment of Nutritional Status\n', ' At risk for malnutrition\n', ' Pt at risk due to: NPO / hypocaloric diet\n', ' Estimated Nutritional Needs\n', ' Calories: 1625-[**2114**] (25-30 cal/kg)\n', ' Protein: 78-91 (1.2-1.4 g/kg)\n', ' Fluid: per team\n', ' Estimation of previous intake: Likely Adequate\n', ' Estimation of current intake: Inadequate\n', ' Specifics: 57 year old male transferred from OSH, intubated there. Pt\n', ' S/P fall CT shows Stage IV splenic laceration. Tolerating TF with\n', ' minimal residuals [**Name8 (MD) **] RN. Current TF provides 1440 kcals/89 g Pro.\n', ' Recommend changing TF to better meet nutritional needs.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' 1. Check chemistry 10 panel daily\n', ' 2. Change TF to goal of Fibersource HN @ 65ml/hr (1872 kcals/83 g\n', ' Pro)\n', ' 3. Pls page with questions [**Numeric Identifier 2584**]\n', '"\n', '40493,Nutrition,"Subjective\n', ' intubated\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 168 cm\n', ' 65 kg\n', ' 23.1\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 64.4 kg\n', ' 101%\n', ' Diagnosis: S/P Fall\n', ' PMH : etoh, smoker, cirrhosis\n', ' Food allergies and intolerances: NKFA\n', ' Pertinent medications: fentanyl, LR @ 10 ml/hr, lasix, versed, RISS, IV\n', ' abx, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 155 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Glucose Finger Stick\n', ' 151\n', ' [**2172-11-2**] 08:00 AM\n', ' BUN\n', ' 17 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Creatinine\n', ' 0.8 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Sodium\n', ' 146 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' Potassium\n', ' 3.6 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' Chloride\n', ' 111 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' TCO2\n', ' 29 mEq/L\n', ' [**2172-11-2**] 12:18 PM\n', ' PO2 (arterial)\n', ' 113 mm Hg\n', ' [**2172-11-2**] 11:55 AM\n', ' PCO2 (arterial)\n', ' 41 mm Hg\n', ' [**2172-11-2**] 11:55 AM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2172-11-2**] 11:55 AM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2172-11-1**] 06:06 PM\n', ' CO2 (Calc) arterial\n', ' 30 mEq/L\n', ' [**2172-11-2**] 11:55 AM\n', ' Albumin\n', ' 3.0 g/dL\n', ' [**2172-10-31**] 02:55 AM\n', ' Calcium non-ionized\n', ' 8.1 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Phosphorus\n', ' 2.5 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' Ionized Calcium\n', ' 1.16 mmol/L\n', ' [**2172-11-2**] 11:55 AM\n', ' Magnesium\n', ' 1.7 mg/dL\n', ' [**2172-11-2**] 12:18 PM\n', ' ALT\n', ' 14 IU/L\n', ' [**2172-10-31**] 02:55 AM\n', ' Alkaline Phosphate\n', ' 73 IU/L\n', ' [**2172-10-31**] 02:55 AM\n', ' AST\n', ' 43 IU/L\n', ' [**2172-10-31**] 02:55 AM\n', ' Total Bilirubin\n', ' 3.4 mg/dL\n', ' [**2172-10-31**] 02:55 AM\n', ' WBC\n', ' 23.2 K/uL\n', ' [**2172-11-2**] 01:06 AM\n', ' Hgb\n', ' 9.1 g/dL\n', ' [**2172-11-2**] 01:06 AM\n', ' Hematocrit\n', ' 27.2 %\n', ' [**2172-11-2**] 01:06 AM\n', ' Current diet order / nutrition support: NPO replete with fiber @ 60\n', ' ml/hr\n', ' GI: OGT\n', ' Assessment of Nutritional Status\n', ' At risk for malnutrition\n', ' Pt at risk due to: NPO / hypocaloric diet\n', ' Estimated Nutritional Needs\n', ' Calories: 1625-[**2114**] (25-30 cal/kg)\n', ' Protein: 78-91 (1.2-1.4 g/kg)\n', ' Fluid: per team\n', ' Estimation of previous intake: Likely Adequate\n', ' Estimation of current intake: Inadequate\n', ' Specifics: 57 year old male transferred from OSH, intubated there. Pt\n', ' S/P fall CT shows Stage IV splenic laceration. Tolerating TF with\n', ' minimal residuals [**Name8 (MD) **] RN. Current TF provides 1440 kcals/89 g Pro.\n', ' Recommend changing TF to better meet nutritional needs.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' 1. Check chemistry 10 panel daily\n', ' 2. Change TF to goal of Fibersource HN @ 65ml/hr (1872 kcals/83 g\n', ' Pro)\n', ' 3. Pls page with questions [**Numeric Identifier 2584**]\n', '"\n', '61565,Nutrition,"Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 88.2 kg\n', ' 27.8\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 75.3 kg\n', ' 117%\n', ' Diagnosis: Head Bleed\n', ' PMH : DM.\n', ' Food allergies and intolerances:\n', ' Pertinent medications: Esmolol, famotidine, colace, lytes ss, dilantin,\n', ' ssri, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 143 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Glucose Finger Stick\n', ' 155\n', ' [**2100-11-1**] 02:00 AM\n', ' BUN\n', ' 18 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Creatinine\n', ' 0.8 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Sodium\n', ' 142 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' Potassium\n', ' 4.1 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' Chloride\n', ' 111 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' TCO2\n', ' 26 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' PO2 (arterial)\n', ' 109 mm Hg\n', ' [**2100-11-1**] 04:35 AM\n', ' PCO2 (arterial)\n', ' 38 mm Hg\n', ' [**2100-11-1**] 04:35 AM\n', ' pH (arterial)\n', ' 7.48 units\n', ' [**2100-11-1**] 04:35 AM\n', ' CO2 (Calc) arterial\n', ' 29 mEq/L\n', ' [**2100-11-1**] 04:35 AM\n', ' Albumin\n', ' 3.8 g/dL\n', ' [**2100-10-30**] 03:27 AM\n', ' Calcium non-ionized\n', ' 8.9 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Phosphorus\n', ' 2.5 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Ionized Calcium\n', ' 1.22 mmol/L\n', ' [**2100-10-31**] 02:41 AM\n', ' Magnesium\n', ' 2.3 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Phenytoin (Dilantin)\n', ' 10.1 ug/mL\n', ' [**2100-10-31**] 02:34 AM\n', ' WBC\n', ' 12.1 K/uL\n', ' [**2100-11-1**] 02:37 AM\n', ' Hgb\n', ' 11.9 g/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Hematocrit\n', ' 33.9 %\n', ' [**2100-11-1**] 02:37 AM\n', ' Current diet order / nutrition support: Replete with fiber Full\n', ' strength; Goal rate: 65 ml/hr\n', ' Residual Check: q4h Hold feeding for residual >= : 200 ml\n', ' GI:\n', ' Assessment of Nutritional Status\n', ' At risk for malnutrition\n', ' Pt at risk due to: NPO / hypocaloric diet\n', ' Estimated Nutritional Needs\n', ' Calories: [**2027**]-2200 (BEE x or / 22-25 cal/kg)\n', ' Protein: 114 (1.3 g/kg)\n', ' Fluid:\n', ' Estimation of previous intake: Adequate\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' 72 yo male s/p witnessed fall w/ head trauma, right parietal-occipital\n', ' SAH w/ left intraparenchymal bleed / contre-coup injury. Pt started on\n', ' TF yesterday, currently tol goal TF without issue, per chart, pt with +\n', ' gag, will plan to extubate this am. If unable to extubate, will need\n', " to change TF to better meet pt's needs.\n", ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Tube feeding recommendations:\n', ' Check chemistry 10 panel daily and replete\n', ' Cont Bg management\n', ' Pplease page [**Numeric Identifier 1550**] if has ?\n', '"\n', '61565,Nutrition,"Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm est.\n', ' 88.2 kg\n', ' 27.8\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 75.3 kg\n', ' 117%\n', ' Diagnosis: Head Bleed\n', ' PMH : DM, HTN\n', ' Food allergies and intolerances:\n', ' Pertinent medications: Esmolol, famotidine, colace, lytes ss, dilantin,\n', ' ssri, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 143 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Glucose Finger Stick\n', ' 155\n', ' [**2100-11-1**] 02:00 AM\n', ' BUN\n', ' 18 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Creatinine\n', ' 0.8 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Sodium\n', ' 142 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' Potassium\n', ' 4.1 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' Chloride\n', ' 111 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' TCO2\n', ' 26 mEq/L\n', ' [**2100-11-1**] 02:37 AM\n', ' PO2 (arterial)\n', ' 109 mm Hg\n', ' [**2100-11-1**] 04:35 AM\n', ' PCO2 (arterial)\n', ' 38 mm Hg\n', ' [**2100-11-1**] 04:35 AM\n', ' pH (arterial)\n', ' 7.48 units\n', ' [**2100-11-1**] 04:35 AM\n', ' CO2 (Calc) arterial\n', ' 29 mEq/L\n', ' [**2100-11-1**] 04:35 AM\n', ' Albumin\n', ' 3.8 g/dL\n', ' [**2100-10-30**] 03:27 AM\n', ' Calcium non-ionized\n', ' 8.9 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Phosphorus\n', ' 2.5 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Ionized Calcium\n', ' 1.22 mmol/L\n', ' [**2100-10-31**] 02:41 AM\n', ' Magnesium\n', ' 2.3 mg/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Phenytoin (Dilantin)\n', ' 10.1 ug/mL\n', ' [**2100-10-31**] 02:34 AM\n', ' WBC\n', ' 12.1 K/uL\n', ' [**2100-11-1**] 02:37 AM\n', ' Hgb\n', ' 11.9 g/dL\n', ' [**2100-11-1**] 02:37 AM\n', ' Hematocrit\n', ' 33.9 %\n', ' [**2100-11-1**] 02:37 AM\n', ' Current diet order / nutrition support: Replete with fiber Full\n', ' strength; Goal rate: 65 ml/hr (1560kcal/96.7g pro)\n', ' Residual Check: q4h Hold feeding for residual >= : 200 ml\n', ' GI: Soft, Non-distended, Non-tender\n', ' Assessment of Nutritional Status\n', ' At risk for malnutrition\n', ' Pt at risk due to: NPO\n', ' Estimated Nutritional Needs\n', ' Calories: 1760-2200 (BEE x or / 20-25 cal/kg)\n', ' Protein: 114 (1.3 g/kg)\n', ' Fluid: per team\n', ' Estimation of previous intake: likely adequate\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' 72 yo male s/p witnessed fall w/ head trauma, right parietal-occipital\n', ' SAH w/ left intraparenchymal bleed / contre-coup injury. Pt started on\n', ' TF yesterday, currently tol goal TF without issue, per chart, pt with +\n', ' gag, cough, [**Last Name (LF) 1080**], [**First Name3 (LF) **] plan to extubate this am. If unable to\n', " extubate, will need to change TF to better meet pt's needs.\n", ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Tube feeding recommendations: increase TF to Replete with Fiber goal\n', ' 75ml/hr (1800kcal/112g pro)\n', ' Check chemistry 10 panel daily and replete prn\n', ' Cont Bg management\n', ' Please page [**Numeric Identifier 1550**] if has ?\n', '"\n', '61565,Nutrition,"Objective\n', ' Pertinent medications: pepcid, Heparin, docusate, Abx, RISS, others\n', ' noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 128 mg/dL\n', ' [**2100-11-5**] 03:32 AM\n', ' Glucose Finger Stick\n', ' 140\n', ' [**2100-11-4**] 08:00 PM\n', ' BUN\n', ' 18 mg/dL\n', ' [**2100-11-5**] 03:32 AM\n', ' Creatinine\n', ' 0.7 mg/dL\n', ' [**2100-11-5**] 03:32 AM\n', ' Sodium\n', ' 140 mEq/L\n', ' [**2100-11-5**] 03:32 AM\n', ' Potassium\n', ' 3.9 mEq/L\n', ' [**2100-11-5**] 03:32 AM\n', ' Chloride\n', ' 103 mEq/L\n', ' [**2100-11-5**] 03:32 AM\n', ' TCO2\n', ' 28 mEq/L\n', ' [**2100-11-5**] 03:32 AM\n', ' PO2 (arterial)\n', ' 94.[**Numeric Identifier 126**] mm Hg\n', ' [**2100-11-5**] 07:26 AM\n', ' PCO2 (arterial)\n', ' 37 mm Hg\n', ' [**2100-11-5**] 07:26 AM\n', ' pH (arterial)\n', ' 7.49 units\n', ' [**2100-11-5**] 07:26 AM\n', ' pH (urine)\n', ' 7.0 units\n', ' [**2100-11-5**] 11:05 AM\n', ' CO2 (Calc) arterial\n', ' 29 mEq/L\n', ' [**2100-11-5**] 07:26 AM\n', ' Calcium non-ionized\n', ' 8.7 mg/dL\n', ' [**2100-11-4**] 02:31 AM\n', ' Phosphorus\n', ' 3.0 mg/dL\n', ' [**2100-11-4**] 02:31 AM\n', ' Magnesium\n', ' 2.3 mg/dL\n', ' [**2100-11-4**] 02:31 AM\n', ' WBC\n', ' 12.2 K/uL\n', ' [**2100-11-5**] 03:32 AM\n', ' Hgb\n', ' 12.0 g/dL\n', ' [**2100-11-5**] 03:32 AM\n', ' Hematocrit\n', ' 33.8 %\n', ' [**2100-11-5**] 03:32 AM\n', ' Current diet order / nutrition support: Replete c/ Fiber @65mL/hr (1560\n', ' kcals/97 gr aa)\n', ' GI: Abd: soft/+bs\n', ' Assessment of Nutritional Status\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' Pt s/p trach/PEG/and IVC filter yesterday. TF\n', 's currently infusing @\n', ' 10mL/hr. Current goal Rx will meet 88% estimated kcal and 85% estimated\n', ' aa needs therefore, will need to increase goal rate of TF\n', 's to avoid\n', ' underfeeding. .\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Multivitamin / Mineral supplement: vua TF\n', ' Tube feeding recommendations: Increase TF goal rate to 75 mL/hr (1800\n', ' kcals/112 gr aa)\n', ' BG management as you are\n', " Please page c/?'s #[**Numeric Identifier 1684**]\n", '"\n', '98851,Nutrition,"Patient has been NPO and/or on unsupplemented clear liquid diet for 1\n', " days. If patient's diet is not able to be advanced and tolerated,\n", ' [**Street Address(1) 1511**] for nutrition support\n', ' Potential for nutrition risk. Patient being monitored. Current\n', ' intervention if any, listed below:\n', ' Comments:\n', ' Pt s/p LRRT [**4-17**], c/b hypoxia and increased O2 requirements in PACU, on\n', ' clears, tolerating well. Clinically improving, possibly transfer to\n', ' floor soon.\n', ' If unable to advance diet further in 24-48hrs, patient may benefit from\n', ' nutrition support.\n', ' Will f/u with progress, po tolerance.\n', ' Please page w/ questions #[**Numeric Identifier 1687**]\n', ' 12:11\n', '"\n', '58054,Nutrition,"Comments:\n', ' Screening per hospital nutrition protocol. Noted patient is comfort\n', ' measures only. No nutrition support indicated at this time. Will sign\n', ' off. Please consult if needed. #[**Numeric Identifier 2337**]\n', '"\n', '99573,Nutrition,"Subjective\n', ' patient confused, unable to answer questions per chart patient had\n', ' difficulty swallowing PTA d/t damaged salivary glands from XRT\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 168 cm\n', ' 98.2 kg\n', ' 34.9\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 59 kg\n', ' 166%\n', ' 68.8 kg\n', ' Diagnosis: facial fx\n', ' PMH : breast ca, tongue ca, ovarian ca, polymyalgia, NIDDM, vertigo, hx\n', ' of falls\n', ' Food allergies and intolerances: none noted\n', ' Pertinent medications: RISS, IV abx, protonix, KCl (30 mEq), Dextrose\n', ' 5% 1/2 normal saline with KCl, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 206\n', ' [**2181-6-5**] 08:00 AM\n', ' Glucose Finger Stick\n', ' 222\n', ' [**2181-6-4**] 08:00 PM\n', ' BUN\n', ' 11 mg/dL\n', ' [**2181-6-4**] 11:36 PM\n', ' Creatinine\n', ' 0.5 mg/dL\n', ' [**2181-6-4**] 11:36 PM\n', ' Sodium\n', ' 134 mEq/L\n', ' [**2181-6-4**] 11:36 PM\n', ' Potassium\n', ' 4.1 mEq/L\n', ' [**2181-6-5**] 09:13 AM\n', ' Chloride\n', ' 98 mEq/L\n', ' [**2181-6-4**] 11:36 PM\n', ' TCO2\n', ' 26 mEq/L\n', ' [**2181-6-4**] 11:36 PM\n', ' pH (urine)\n', ' 6.5 units\n', ' [**2181-6-3**] 12:30 AM\n', ' Calcium non-ionized\n', ' 8.5 mg/dL\n', ' [**2181-6-4**] 11:36 PM\n', ' Phosphorus\n', ' 2.3 mg/dL\n', ' [**2181-6-4**] 11:36 PM\n', ' Magnesium\n', ' 2.0 mg/dL\n', ' [**2181-6-4**] 11:36 PM\n', ' WBC\n', ' 9.2 K/uL\n', ' [**2181-6-5**] 12:03 AM\n', ' Hgb\n', ' 10.9 g/dL\n', ' [**2181-6-5**] 12:03 AM\n', ' Hematocrit\n', ' 32.7 %\n', ' [**2181-6-5**] 12:03 AM\n', ' Current diet order / nutrition support: NPO\n', ' GI: obese, + bowel sounds\n', ' Assessment of Nutritional Status\n', ' Obese, At risk for malnutrition\n', ' Pt at risk due to: NPO / hypocaloric diet, trauma\n', ' Estimated Nutritional Needs based on adjusted body wt\n', ' Calories: 1513-1720 (22-25 cal/kg)\n', ' Protein: 83-103 (1.2-1.5 g/kg)\n', ' Fluid: per team\n', ' Estimation of previous intake: unknown\n', ' Estimation of current intake: Inadequate d/t NPO status\n', ' Specifics: 78 year old female admitted from outside hospital S/P fall\n', ' at home with multiple injuries including Le Forte fx, multiple sinus\n', ' fx, orbital fx, facial and tongue swelling. Patient seen by SLP on [**6-4**]\n', ' who recommended patient remain NPO. If patient\n', 's diet cannot be\n', ' advanced consider initiating tube feedings to prevent further\n', ' nutritional decline.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' If diet cannot be advanced recommend starting tube feedings start with\n', ' Replete with Fiber @ 15 ml/hr advance to goal of 65 ml/hr =1560\n', ' kcals/97 g protein\n', ' Check residuals q 4-6 hours hold if greater than 150 cc\n', ' Monitor lytes and glucose with initiation of tube feeding\n', ' Change to non-dextrose IV fluids once tube feedings started\n', ' Implement any SLP recs\n', ' Will continue to follow page [**Numeric Identifier 1372**] with questions\n', '"\n', '40461,Nutrition,"Subjective\n', ' oriented x1\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 74.9 kg ([**2113-2-3**] 04:00 AM)\n', ' 19.9\n', ' Pertinent medications: Ranitidine, Multi-vitamin, ABX, Folic Acid,\n', ' Thiamine, Coumadin, Lasix, Colace (held), KCl (20mEq repletion x2),\n', ' Magnesium sulfate (2g repletion), Heparin drip\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 105 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Glucose Finger Stick\n', ' 127\n', ' [**2113-2-3**] 12:00 PM\n', ' BUN\n', ' 25 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Creatinine\n', ' 1.8 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Sodium\n', ' 142 mEq/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Potassium\n', ' 3.9 mEq/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Chloride\n', ' 110 mEq/L\n', ' [**2113-2-3**] 05:24 AM\n', ' TCO2\n', ' 25 mEq/L\n', ' [**2113-2-3**] 05:24 AM\n', ' PO2 (arterial)\n', ' 65 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 30 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2113-1-31**] 04:47 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.5 units\n', ' [**2113-2-1**] 07:16 AM\n', ' CO2 (Calc) arterial\n', ' 22 mEq/L\n', ' [**2113-1-31**] 04:47 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.1 g/dL\n', ' [**2113-2-1**] 02:44 PM\n', ' Calcium non-ionized\n', ' 7.5 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Phosphorus\n', ' 3.0 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Ionized Calcium\n', ' 1.08 mmol/L\n', ' [**2113-1-30**] 11:46 AM\n', ' Magnesium\n', ' 2.3 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' ALT\n', ' 23 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Alkaline Phosphate\n', ' 51 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' AST\n', ' 24 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Amylase\n', ' 40 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Total Bilirubin\n', ' 0.3 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 9.3 K/uL\n', ' [**2113-2-3**] 05:24 AM\n', ' Hgb\n', ' 8.9 g/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Hematocrit\n', ' 27.0 %\n', ' [**2113-2-3**] 05:24 AM\n', ' Current diet order / nutrition support: Diet: NPO\n', ' Calorie counts: [**2-1**] - 17 - 18\n', ' GI: soft, (+) bowel sounds; 500ml stool today\n', ' Assessment of Nutritional Status\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' 49 year old male with mitral valve endocarditis, preop stroke s/p MVR\n', ' (29mm [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1104**] [**Last Name (NamePattern1) 1105**]) debridement of aortic valve [**1-27**]. Patient with\n', ' prolonged poor po\n', 's during admit. Was on ground solids + thin liquid\n', ' diet, refusing po\n', 's at times. s/p calories counts\n', ' 880 calories [**2-1**]\n', ' and 270 calories [**2-2**]. Seen for video swallow evaluation this AM\n', ' SLP recommend NPO. Per discussion with PA\n', ' plan for PEG placement as\n', ' previously unable to place NGT and feel that patient will pull it out.\n', ' Agree with PEG for long term nutrition support to prevent further\n', ' nutritional decline and optimize nutrition for post-op healing. Noted\n', ' multiple lyte repletions.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Current diet / nutrition support is appropriate: continue\n', ' NPO per SLP recommendations\n', ' o SLP follow up when appropriate\n', ' Tube feeding recommendations: Agree with PEG\n', ' o Once feeding tube placed, recommend begin Isosource 1.5 @\n', ' 20ml/hr, advance as tolerated to goal of 45ml/hr = 1620 calories and\n', ' 73g protein\n', ' Check residuals, hold tube feed if greater than 200ml\n', ' Multivitamin / Mineral supplement: continue current\n', ' Check chemistry 10 panel daily\n', ' o Replete lytes PRN\n', ' Will follow, page if questions *[**Numeric Identifier 606**]\n', '"\n', '40461,Nutrition,"Subjective\n', ' Patient oob, tube feed running at 40 ml/hr.\n', ' Objective\n', ' Pertinent medications: noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 119\n', ' [**2113-2-8**] 08:00 AM\n', ' Glucose Finger Stick\n', ' 150\n', ' [**2113-2-7**] 10:00 PM\n', ' BUN\n', ' 31 mg/dL\n', ' [**2113-2-8**] 02:50 AM\n', ' Creatinine\n', ' 2.0 mg/dL\n', ' [**2113-2-8**] 02:50 AM\n', ' Sodium\n', ' 143 mEq/L\n', ' [**2113-2-8**] 02:50 AM\n', ' Potassium\n', ' 3.4 mEq/L\n', ' [**2113-2-8**] 07:52 AM\n', ' Chloride\n', ' 109 mEq/L\n', ' [**2113-2-8**] 02:50 AM\n', ' TCO2\n', ' 25 mEq/L\n', ' [**2113-2-8**] 02:50 AM\n', ' PO2 (arterial)\n', ' 65 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 30 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2113-1-31**] 04:47 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-2-7**] 05:19 PM\n', ' pH (urine)\n', ' 5.5 units\n', ' [**2113-2-1**] 07:16 AM\n', ' CO2 (Calc) arterial\n', ' 22 mEq/L\n', ' [**2113-1-31**] 04:47 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.2 g/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Calcium non-ionized\n', ' 7.8 mg/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Phosphorus\n', ' 4.0 mg/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Ionized Calcium\n', ' 1.07 mmol/L\n', ' [**2113-2-7**] 05:19 PM\n', ' Magnesium\n', ' 2.1 mg/dL\n', ' [**2113-2-8**] 07:52 AM\n', ' ALT\n', ' 21 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' Alkaline Phosphate\n', ' 50 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' AST\n', ' 23 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' Amylase\n', ' 45 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' Total Bilirubin\n', ' 0.4 mg/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 10.1 K/uL\n', ' [**2113-2-8**] 02:50 AM\n', ' Hgb\n', ' 8.3 g/dL\n', ' [**2113-2-8**] 02:50 AM\n', ' Hematocrit\n', ' 26.1 %\n', ' [**2113-2-8**] 02:50 AM\n', ' Current diet order / nutrition support: Replete with fiber Full\n', ' strength;\n', ' Starting rate: 40 ml/hr; Advance rate by 20 ml q6h Goal rate: 70 ml/hr\n', ' Residual Check: q4h Hold feeding for residual >= : 200 ml\n', ' Flush w/ 30 ml water q8h\n', ' GI: Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n', ' PEG site clean and dry.\n', ' Assessment of Nutritional Status\n', ' 49 year old male s/p PEG placement yesterday, tube feed started\n', ' yesterday, tolerated Isosource 1.5 well, tube feed ordered changed to\n', ' Replete with fiber this morning, spoke to team, does not want patient\n', ' on special tube feed, recommend change to Fibersource HN as current\n', ' formula provides excess amount of protein. Noted discharge planning in\n', ' progress.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Tube feeding: Fibersource HN goal 60ml/hr ( 1728kcal/76g\n', ' protein)\n', ' Check chemistry 10 panel daily, replete prn\n', ' Continue BS management\n', ' [**Numeric Identifier 943**] if has question\n', '"\n', '40461,Nutrition,"Subjective\n', ' Patient asleep.\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 70.8 kg ([**2113-2-7**] 04:00 AM)\n', ' 19.9\n', ' Pertinent medications: Multiple Vitamins, Furosemide, Docusate Sodium,\n', ' others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 157 mg/dL\n', ' [**2113-2-7**] 04:00 AM\n', ' Glucose Finger Stick\n', ' 158\n', ' [**2113-2-7**] 06:00 AM\n', ' BUN\n', ' 33 mg/dL\n', ' [**2113-2-7**] 04:00 AM\n', ' Creatinine\n', ' 1.9 mg/dL\n', ' [**2113-2-7**] 04:00 AM\n', ' Sodium\n', ' 145 mEq/L\n', ' [**2113-2-7**] 04:00 AM\n', ' Potassium\n', ' 3.7 mEq/L\n', ' [**2113-2-7**] 04:00 AM\n', ' Chloride\n', ' 111 mEq/L\n', ' [**2113-2-7**] 04:00 AM\n', ' TCO2\n', ' 24 mEq/L\n', ' [**2113-2-7**] 04:00 AM\n', ' PO2 (arterial)\n', ' 65 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 30 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2113-1-31**] 04:47 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.5 units\n', ' [**2113-2-1**] 07:16 AM\n', ' CO2 (Calc) arterial\n', ' 22 mEq/L\n', ' [**2113-1-31**] 04:47 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.2 g/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Calcium non-ionized\n', ' 7.8 mg/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Phosphorus\n', ' 4.0 mg/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Ionized Calcium\n', ' 1.08 mmol/L\n', ' [**2113-1-30**] 11:46 AM\n', ' Magnesium\n', ' 2.0 mg/dL\n', ' [**2113-2-6**] 11:00 PM\n', ' ALT\n', ' 21 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' Alkaline Phosphate\n', ' 50 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' AST\n', ' 23 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' Amylase\n', ' 45 IU/L\n', ' [**2113-2-6**] 04:05 AM\n', ' Total Bilirubin\n', ' 0.4 mg/dL\n', ' [**2113-2-6**] 04:05 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 12.3 K/uL\n', ' [**2113-2-7**] 04:00 AM\n', ' Hgb\n', ' 8.8 g/dL\n', ' [**2113-2-7**] 04:00 AM\n', ' Hematocrit\n', ' 26.9 %\n', ' [**2113-2-7**] 04:00 AM\n', ' Current diet order / nutrition support: Non-Standard TPN For Date:\n', ' [**2113-2-6**] (1600ml, 270drextrose/80protein/35fat)\n', ' Replete with fiber Full strength;\n', ' Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 60 ml/hr\n', ' Residual Check: q4h Hold feeding for residual >= : 200 ml\n', ' Flush w/ 30 ml water q8h\n', ' GI: Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n', ' PEG site clean and dry. Peg to gravity drainage\n', ' Assessment of Nutritional Status\n', ' 49 year old male with Mitral valve endocarditis, preop stroke s/p MVR\n', ' and debridement of aortic valve [**1-27**], patient failed S & S evaluation,\n', ' TPN started over the weekend while awaiting PEG. PEG placed\n', ' yesterday, plan to start tube feeds today, current tube feed order not\n', ' meeting patient\n', 's estimated need. Noted patient with post op fluid\n', ' gain, recommend fluid restricted formula.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Consider ordering day 1 TPN tonight while slowly advancing\n', ' tube feed\n', ' Tube feeding: Isosource 1.5cal goal 45ml/hr ( 1620kcal/73g\n', ' protein)\n', ' Start tube feed at 15ml/hr and adv slowly as tol\n', ' Check chemistry 10 panel daily, replete prn\n', ' Continue BS management\n', ' [**Numeric Identifier 943**] if has question\n', '"\n', '40461,Nutrition,"Subjective\n', ' patient sleeping\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 74.9 kg ([**2113-2-3**] 04:00 AM)\n', ' 19.9\n', ' Pertinent medications: D5 @10 ml/hr, KCl (40 mEq repletion), RISS, IV\n', ' abx, lansoprazole, famotidine, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 73\n', ' [**2113-2-4**] 12:00 PM\n', ' Glucose Finger Stick\n', ' 135\n', ' [**2113-2-4**] 12:00 AM\n', ' BUN\n', ' 25 mg/dL\n', ' [**2113-2-4**] 03:42 AM\n', ' Creatinine\n', ' 1.6 mg/dL\n', ' [**2113-2-4**] 03:42 AM\n', ' Sodium\n', ' 140 mEq/L\n', ' [**2113-2-4**] 03:42 AM\n', ' Potassium\n', ' 3.5 mEq/L\n', ' [**2113-2-4**] 03:42 AM\n', ' Chloride\n', ' 108 mEq/L\n', ' [**2113-2-4**] 03:42 AM\n', ' TCO2\n', ' 22 mEq/L\n', ' [**2113-2-4**] 03:42 AM\n', ' PO2 (arterial)\n', ' 65 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 30 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2113-1-31**] 04:47 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.5 units\n', ' [**2113-2-1**] 07:16 AM\n', ' CO2 (Calc) arterial\n', ' 22 mEq/L\n', ' [**2113-1-31**] 04:47 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.1 g/dL\n', ' [**2113-2-1**] 02:44 PM\n', ' Calcium non-ionized\n', ' 7.3 mg/dL\n', ' [**2113-2-4**] 03:42 AM\n', ' Phosphorus\n', ' 3.1 mg/dL\n', ' [**2113-2-4**] 03:42 AM\n', ' Ionized Calcium\n', ' 1.08 mmol/L\n', ' [**2113-1-30**] 11:46 AM\n', ' Magnesium\n', ' 2.0 mg/dL\n', ' [**2113-2-4**] 03:42 AM\n', ' ALT\n', ' 23 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Alkaline Phosphate\n', ' 51 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' AST\n', ' 24 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Amylase\n', ' 40 IU/L\n', ' [**2113-2-3**] 05:24 AM\n', ' Total Bilirubin\n', ' 0.3 mg/dL\n', ' [**2113-2-3**] 05:24 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 13.4 K/uL\n', ' [**2113-2-4**] 03:42 AM\n', ' Hgb\n', ' 9.8 g/dL\n', ' [**2113-2-4**] 03:42 AM\n', ' Hematocrit\n', ' 29.7 %\n', ' [**2113-2-4**] 03:42 AM\n', ' Current diet order / nutrition support: NPO\n', ' GI: soft, hypoactive bowel sounds\n', ' Assessment of Nutritional Status\n', ' Specifics: Patient s/p video swallow [**2-3**] which recommended patient be\n', ' NPO. Received consult for PPN recommendations. Per discussion with PA,\n', ' plan is for PEG placement on Monday and to supplement nutrition with\n', ' parenteral nutrition until PEG is able to be used. Patient with PICC,\n', ' Day 1 TPN ordered to start tonight. NGT was attempted earlier in week\n', ' and was unable to placed and team thinks patient would pull it out.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' 1. Day 1 TPN tonight\n', ' 2. Pending glycemic control advance to goal TPN 1.6L (270 g\n', ' dextrose/80 g amino acids/35 g lipids)= 1588 kcals\n', ' 3. Check TG hold lipids if greater than 400\n', ' 4. Once PEG placed start with Isosource HN @ 15 ml/hr advance to\n', ' goal of 45 ml/hr = 1620 kcals/ 73 g protein\n', ' 5. Will follow page [**Numeric Identifier 1372**] with questions\n', '"\n', '40461,Nutrition,"Subjective\n', ' Patient asleep, [**Name8 (MD) 77**] RN, patient refused all po food or supplements.\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 70.5 kg ([**2113-1-19**] 08:00 AM)\n', ' up due to fluid\n', ' 19.9\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 75.3 kg\n', ' 119%\n', ' 63 kg\n', ' 100%\n', ' Diagnosis: MITRAL VALVE ENDOCARDITIS\n', ' PMHx: None - no medical care x 30 years\n', ' Food allergies and intolerances: not available\n', ' Pertinent medications: Furosemide , Milrinone, Multivitamins, Thiamine,\n', ' FoLIC Acid, Nicotine Patch, Heparin, Docusate Sodium , Nafcillin,\n', ' Potassium Chloride, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 117 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' BUN\n', ' 25 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Creatinine\n', ' 1.5 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Sodium\n', ' 137 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Potassium\n', ' 3.3 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Chloride\n', ' 103 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' TCO2\n', ' 22 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' PO2 (venous)\n', ' 145 mm Hg\n', ' [**2113-1-15**] 04:51 PM\n', ' PCO2 (venous)\n', ' 34 mm Hg\n', ' [**2113-1-15**] 04:51 PM\n', ' pH (venous)\n', ' 7.45 units\n', ' [**2113-1-15**] 04:51 PM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2113-1-18**] 12:03 PM\n', ' CO2 (Calc) venous\n', ' 24 mEq/L\n', ' [**2113-1-15**] 04:51 PM\n', ' Albumin\n', ' 1.9 g/dL\n', ' [**2113-1-18**] 07:15 AM\n', ' Calcium non-ionized\n', ' 7.1 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Phosphorus\n', ' 4.8 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Magnesium\n', ' 1.9 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' ALT\n', ' 36 IU/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Alkaline Phosphate\n', ' 44 IU/L\n', ' [**2113-1-20**] 02:36 AM\n', ' AST\n', ' 54 IU/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Total Bilirubin\n', ' 0.4 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' WBC\n', ' 13.0 K/uL\n', ' [**2113-1-20**] 02:36 AM\n', ' Hgb\n', ' 11.8 g/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Hematocrit\n', ' 35.2 %\n', ' [**2113-1-20**] 02:36 AM\n', ' Current diet order / nutrition support: Regular; Supplement: Ensure\n', ' Plus breakfast, lunch, dinner\n', ' GI: Abdominal: Soft, Non-tender, Bowel sounds present\n', ' Extremities: Right lower extremity edema: Absent, Left lower extremity\n', ' edema\n', ' Skin: Warm, Rash: upper and lower ext, occ petechiae\n', ' Assessment of Nutritional Status\n', ' At risk for malnutrition\n', 'Patient at risk due to: Low po intake, current illness, head CT showed multipl\n', 'e small non-hemorrhagic\n', ' infarcts suspicious for septic emboli,\n', ' Estimated Nutritional Needs\n', ' Calories: 1575-1764 (BEE x or / 25-28 cal/kg)\n', ' Protein: 76-88 (1.2-1.4 g/kg)\n', ' Fluid: per team\n', ' Calculations based on: Admit weight\n', ' Estimation of previous intake: Inadequate\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' 49 year old male found to have staphylococcus aureus bacterial\n', ' endocarditis with severe mitral regurgitation [**3-21**] mitral valve\n', ' vegetations and flail leaflet. Patient transferred from [**Hospital **] [**Hospital1 5**] for CT surgery evaluation and further management.\n', ' Patient s/p speech and swallow evaluation, okay to have regular diet,\n', ' yet patient refused to take pos. spoke to team this morning, team\n', ' considering NGT placement.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Po as tolerance\n', ' Tube feeding recommendations: Nutren Pulmonary goal 45ml/hr\n', ' (1620kcal/73.4g protein)\n', ' Monitor tube feed tolerance\n', ' Check chemistry 10 panel daily, replete as you are doing\n', ' Consider adding phos binder if serum phos remains elevated\n', ' Start regular insulin sliding scale if serum glucose greater\n', ' than 150 mg/dL\n', ' Other: [**Numeric Identifier 943**] if has question\n', '"\n', '40461,Nutrition,"Subjective\n', ' Patient asleep, [**Name8 (MD) 77**] RN, patient refused all po food or supplements.\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 70.5 kg ([**2113-1-19**] 08:00 AM)\n', ' up due to fluid\n', ' 19.9\n', ' Ideal body weight\n', ' % Ideal body weight\n', ' Adjusted weight\n', ' Usual body weight\n', ' % Usual body weight\n', ' 75.3 kg\n', ' 119%\n', ' 63 kg\n', ' 100%\n', ' Diagnosis: MITRAL VALVE ENDOCARDITIS\n', ' PMHx: None - no medical care x 30 years\n', ' Food allergies and intolerances: not available\n', ' Pertinent medications: Furosemide , Milrinone, Multivitamins, Thiamine,\n', ' FoLIC Acid, Nicotine Patch, Heparin, Docusate Sodium , Nafcillin,\n', ' Potassium Chloride, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 117 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' BUN\n', ' 25 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Creatinine\n', ' 1.5 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Sodium\n', ' 137 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Potassium\n', ' 3.3 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Chloride\n', ' 103 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' TCO2\n', ' 22 mEq/L\n', ' [**2113-1-20**] 02:36 AM\n', ' PO2 (venous)\n', ' 145 mm Hg\n', ' [**2113-1-15**] 04:51 PM\n', ' PCO2 (venous)\n', ' 34 mm Hg\n', ' [**2113-1-15**] 04:51 PM\n', ' pH (venous)\n', ' 7.45 units\n', ' [**2113-1-15**] 04:51 PM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2113-1-18**] 12:03 PM\n', ' CO2 (Calc) venous\n', ' 24 mEq/L\n', ' [**2113-1-15**] 04:51 PM\n', ' Albumin\n', ' 1.9 g/dL\n', ' [**2113-1-18**] 07:15 AM\n', ' Calcium non-ionized\n', ' 7.1 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Phosphorus\n', ' 4.8 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Magnesium\n', ' 1.9 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' ALT\n', ' 36 IU/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Alkaline Phosphate\n', ' 44 IU/L\n', ' [**2113-1-20**] 02:36 AM\n', ' AST\n', ' 54 IU/L\n', ' [**2113-1-20**] 02:36 AM\n', ' Total Bilirubin\n', ' 0.4 mg/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' WBC\n', ' 13.0 K/uL\n', ' [**2113-1-20**] 02:36 AM\n', ' Hgb\n', ' 11.8 g/dL\n', ' [**2113-1-20**] 02:36 AM\n', ' Hematocrit\n', ' 35.2 %\n', ' [**2113-1-20**] 02:36 AM\n', ' Current diet order / nutrition support: Regular; Supplement: Ensure\n', ' Plus breakfast, lunch, dinner\n', ' GI: Abdominal: Soft, Non-tender, Bowel sounds present\n', ' Extremities: Right lower extremity edema: Absent, Left lower extremity\n', ' edema\n', ' Skin: Warm, Rash: upper and lower ext, occ petechiae\n', ' Assessment of Nutritional Status\n', ' At risk for malnutrition\n', 'Patient at risk due to: Low po intake, current illness, head CT showed multipl\n', 'e small non-hemorrhagic\n', ' infarcts suspicious for septic emboli,\n', ' Estimated Nutritional Needs\n', ' Calories: 1575-1764 (BEE x or / 25-28 cal/kg)\n', ' Protein: 76-88 (1.2-1.4 g/kg)\n', ' Fluid: per team\n', ' Calculations based on: Admit weight\n', ' Estimation of previous intake: Inadequate\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' 49 year old male found to have staphylococcus aureus bacterial\n', ' endocarditis with severe mitral regurgitation [**3-21**] mitral valve\n', ' vegetations and flail leaflet. Patient transferred from [**Hospital **] [**Hospital1 5**] for CT surgery evaluation and further management.\n', ' Patient s/p speech and swallow evaluation, okay to have regular diet,\n', ' yet patient refused to take pos. spoke to team this morning, team\n', ' considering NGT placement.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Po as tolerance\n', ' Tube feeding recommendations: Nutren Pulmonary goal 45ml/hr\n', ' (1620kcal/73.4g protein)\n', ' Monitor tube feed tolerance\n', ' Check chemistry 10 panel daily, replete as you are doing\n', ' Consider adding phos binder if serum phos remains elevated\n', ' Start regular insulin sliding scale if serum glucose greater\n', ' than 150 mg/dL\n', ' Other: [**Numeric Identifier 943**] if has question\n', ' ------ Protected Section ------\n', ' Cardiology Teaching Physician Note\n', ' On this day I saw, examined and was physically present with the\n', ' resident / fellow for the key portions of the services provided. I\n', ' agree with the above note and plans.\n', ' I would add the following remarks:\n', ' Medical Decision Making\n', ' Patient slowly improving the am after aggressive diuresis and\n', ' initiation of Milrinone. He is less dyspneic and saturations are in the\n', ' 95-96% range. Renal service feels ARF is multifactorial and sediment is\n', ' c/w ATM. Createnine is stable today at 1.5. He is speaking clearly but\n', ' somnolent and wife, [**Name (NI) 1880**], feels this is from not sleeping last night.\n', ' WBC down to 13K from 14K yesterday. ID recommends continuing Nafcillin\n', ' with bllod cultures with fever spikes. Source of fevers are unclear now\n', ' and we may need to image his abdomen as he complains of intermittent\n', ' abdominal pain. C-[**Doctor First Name 91**] continues to follow closely and would like to\n', ' delay surgery for as long as possible.\n', ' ------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) **], MD\n', ' on:[**2113-1-20**] 05:48 PM ------\n', '"\n', '40461,Nutrition,"Subjective: Did not speak with patient.\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 72 kg ([**2113-1-22**] 10:00 AM)\n', ' 19.9\n', ' Pertinent medications: Milrinone, protonix, abx, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 98 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' BUN\n', ' 27 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Creatinine\n', ' 1.0 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Sodium\n', ' 137 mEq/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Potassium\n', ' 4.3 mEq/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Chloride\n', ' 107 mEq/L\n', ' [**2113-1-22**] 05:17 AM\n', ' TCO2\n', ' 19 mEq/L\n', ' [**2113-1-22**] 05:17 AM\n', ' PO2 (arterial)\n', ' 61 mm Hg\n', ' [**2113-1-22**] 12:22 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 31 mm Hg\n', ' [**2113-1-22**] 12:22 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.37 units\n', ' [**2113-1-22**] 12:22 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2113-1-20**] 06:24 PM\n', ' CO2 (Calc) arterial\n', ' 19 mEq/L\n', ' [**2113-1-22**] 12:22 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.1 g/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Calcium non-ionized\n', ' 7.6 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Phosphorus\n', ' 3.8 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Magnesium\n', ' 2.0 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' ALT\n', ' 27 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Alkaline Phosphate\n', ' 50 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' AST\n', ' 27 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Total Bilirubin\n', ' 0.3 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' WBC\n', ' 20.7 K/uL\n', ' [**2113-1-22**] 05:17 AM\n', ' Hgb\n', ' 12.9 g/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Hematocrit\n', ' 39.5 %\n', ' [**2113-1-22**] 05:17 AM\n', ' Current diet order / nutrition support: Diet: Regular/ heart healthy,\n', ' with ensure plus TID\n', ' GI: abd soft, bowel sounds present\n', ' Assessment of Nutritional Status\n', ' 49 year old male found to have staphylococcus aureus bacterial\n', ' endocarditis with severe mitral regurgitation [**3-21**] mitral valve\n', ' vegetations and flail leaflet. Patient transferred from [**Hospital **] to [**Hospital1 5**] for CT surgery evaluation and further management.\n', ' Patient s/p speech and swallow evaluation, okay to have regular diet,\n', ' yet patient is only taking small amounts of po\n', 's due to mental status.\n', ' Team is planning to place an NGT for start of tube feeds. Tube\n', ' feeding are recommendations below; these can be adjusted based on\n', ' amount of po\n', 's patient is taking.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' To meet 100% of estimated needs, recommend Nutren Pulmonary\n', ' @ 45mL/hr (1620kcals, 73g protein)\n', ' Will monitor po intake and mental status and adjust tube\n', ' feeds as needed.\n', ' Following g- #[**Numeric Identifier 1312**]\n', '"\n', '40461,Nutrition,"Subjective\n', ' intub\n', ' Objective\n', ' Pertinent medications: Multivitamins, FoLIC Acid , Pantoprazole,\n', ' Potassium Chloride, Norepinephrine drip, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 106 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' BUN\n', ' 15 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' Creatinine\n', ' 1.1 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' Sodium\n', ' 140 mEq/L\n', ' [**2113-1-25**] 03:36 AM\n', ' Potassium\n', ' 3.7 mEq/L\n', ' [**2113-1-25**] 03:36 AM\n', ' Chloride\n', ' 108 mEq/L\n', ' [**2113-1-25**] 03:36 AM\n', ' TCO2\n', ' 26 mEq/L\n', ' [**2113-1-25**] 03:36 AM\n', ' PO2 (arterial)\n', ' 108 mm Hg\n', ' [**2113-1-25**] 03:53 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 53 mm Hg\n', ' [**2113-1-25**] 03:53 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.32 units\n', ' [**2113-1-25**] 03:53 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2113-1-25**] 02:26 PM\n', ' CO2 (Calc) arterial\n', ' 29 mEq/L\n', ' [**2113-1-25**] 03:53 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.1 g/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Calcium non-ionized\n', ' 7.4 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' Phosphorus\n', ' 3.5 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' Magnesium\n', ' 1.6 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' ALT\n', ' 27 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Alkaline Phosphate\n', ' 50 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' AST\n', ' 27 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Amylase\n', ' 25 IU/L\n', ' [**2113-1-22**] 05:17 AM\n', ' Total Bilirubin\n', ' 0.3 mg/dL\n', ' [**2113-1-22**] 05:17 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 11.4 K/uL\n', ' [**2113-1-25**] 03:36 AM\n', ' Hgb\n', ' 9.6 g/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' Hematocrit\n', ' 30.3 %\n', ' [**2113-1-25**] 03:36 AM\n', ' Current diet order / nutrition support: Nutren Pulmonary Full strength;\n', ' Additives: Banana flakes, 3 packets per day\n', ' Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 45 ml/hr\n', ' Residual Check: q4h Hold feeding for residual >= : 200 ml\n', ' Flush w/ 100 ml water q8h ( not running since 8 am this morning)\n', ' NPO for Procedure Start: After 12:01AM Procedure: CSURG on date\n', ' [**2113-1-26**]\n', ' Do NOT resume diet after procedure.\n', ' GI: Abd: soft, ND, NT, NBS\n', ' Ext: 2+ pulses, 2+ edema in lower extremtiies R>L\n', ' Assessment of Nutritional Status\n', ' 49 year old male found to have staphlyococcus aureus bacterial\n', ' endocarditis with severe mitral regurgitation [**3-21**] mitral valve\n', ' vegetations and flail leaflet, patient pending OR tomorrow for AVR and\n', ' MVR with debridement of the epidural abscess. Patient received minimal\n', ' nutrition since admission (had <24hours tube feed from 12/7-8), at very\n', ' high risk for malnutrition, recommend closely monitor post cardiac\n', ' surgery, may need to restart tube feed as patient was refusing all po\n', ' food this admission.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Multivitamin / Mineral supplement: discontinue outside order\n', ' if tube feed restarts\n', ' Tube feeding recommendations: restart tube feed as ordered\n', ' Check chemistry 10 panel daily, replete as you are doing\n', ' Start regular insulin sliding scale if serum glucose greater\n', ' than 150 mg/dL\n', ' Other: [**Numeric Identifier 943**] if has question\n', '"\n', '40461,Nutrition,"Ht: 70\n', ' Wt: 57.8 kg\n', ' IBW: 75.3 kg/ 77%\n', ' BMI: 18.2\n', ' Pmh: Diabetes,Dyslipidemia,Hypertension, [**1-25**] multiple embolic events\n', ' worst is large left posterior cerebral artery infarct(neurologic\n', ' deficits including left sided facial droop, right sided neglect, right\n', ' sided hemiparesis, expressive aphasia),\n', ' MVR(29mm St. [**Male First Name (un) 1104**] Mechanical Valve) with Debridement of Aortic Valve.\n', ' Teeth extraction [**2113-1-23**].\n', ' Diet Order: regular\n', ' 49 year old male was in rehab s/p M. Patient admitted to outside\n', ' hospital CT showed depressed fx of right frontal sinus. Patient\n', ' transferred\n', ' Potential for nutrition risk. Patient being monitored. Current\n', ' intervention if any, listed below:\n', ' Comments:\n', '"\n', '40461,Nutrition,"Ht: 70\n', ' Wt: 57.8 kg\n', ' IBW: 75.3 kg/ 77%\n', ' BMI: 18.2\n', ' Pmh: Diabetes,Dyslipidemia,Hypertension, [**1-25**] multiple embolic events\n', ' worst is large left posterior cerebral artery infarct(neurologic\n', ' deficits including left sided facial droop, right sided neglect, right\n', ' sided hemiparesis, expressive aphasia),\n', ' MVR(29mm St. [**Male First Name (un) 1104**] Mechanical Valve) with Debridement of Aortic Valve.\n', ' Teeth extraction [**2113-1-23**].\n', ' Diet Order: regular\n', ' 49 year old male on coumadin for a prosthetic mitral valve after\n', ' having Staphylococcal endocarditis of MV and AV, c/b multiple embolic\n', ' strokes admitted from rehab s/p fall. Patient tolerating diet no nausea\n', ' or vomiting. Patient reports much better po intake since admit to\n', ' [**Hospital1 5**]. Patient unsure of wt loss PTA and unsure of usual body wt. Will\n', ' add supplements to increase caloric intake.\n', ' Recommendations:\n', ' 1. Encourage pos and supplements\n', ' 2. Will add ensure TID\n', ' 3. Will follow page [**Numeric Identifier 1372**] with questions\n', '"\n', '40461,Nutrition,"Subjective\n', ' oriented x 1\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 72 kg ([**2113-2-1**] 04:00 AM)\n', ' 19.9\n', ' Pertinent medications: Ranitidine, ABX, Folic Acid, Thiamine,\n', ' Multi-vitamin, lasix, Colace (Held), KCl (20mEq repletion x3)\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 108 mg/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' Glucose Finger Stick\n', ' 124\n', ' [**2113-2-1**] 12:00 AM\n', ' BUN\n', ' 28 mg/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' Creatinine\n', ' 2.0 mg/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' Sodium\n', ' 139 mEq/L\n', ' [**2113-2-1**] 03:30 AM\n', ' Potassium\n', ' 3.7 mEq/L\n', ' [**2113-2-1**] 03:30 AM\n', ' Chloride\n', ' 105 mEq/L\n', ' [**2113-2-1**] 03:30 AM\n', ' TCO2\n', ' 23 mEq/L\n', ' [**2113-2-1**] 03:30 AM\n', ' PO2 (arterial)\n', ' 65 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 30 mm Hg\n', ' [**2113-1-31**] 04:47 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.46 units\n', ' [**2113-1-31**] 04:47 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.5 units\n', ' [**2113-2-1**] 07:16 AM\n', ' CO2 (Calc) arterial\n', ' 22 mEq/L\n', ' [**2113-1-31**] 04:47 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.2 g/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Calcium non-ionized\n', ' 7.6 mg/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' Phosphorus\n', ' 4.6 mg/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' Ionized Calcium\n', ' 1.08 mmol/L\n', ' [**2113-1-30**] 11:46 AM\n', ' Magnesium\n', ' 2.2 mg/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' ALT\n', ' 20 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Alkaline Phosphate\n', ' 57 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' AST\n', ' 26 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Amylase\n', ' 17 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Total Bilirubin\n', ' 0.4 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 18.2 K/uL\n', ' [**2113-2-1**] 03:30 AM\n', ' Hgb\n', ' 10.4 g/dL\n', ' [**2113-2-1**] 03:30 AM\n', ' Hematocrit\n', ' 31.5 %\n', ' [**2113-2-1**] 03:30 AM\n', ' Current diet order / nutrition support: Diet: Ground solids, thin\n', ' liquids; Ensure Pudding and Carnation Instant Breakfast with meals;\n', ' calorie counts [**2-1**], [**2-2**], [**2-3**]\n', ' GI: soft, (+) bowel sounds; green liquid stool\n', ' Assessment of Nutritional Status\n', ' Estimation of current intake: Inadequate\n', ' Specifics:\n', ' Patient s/p MVR / AVR [**1-27**]. Extubated [**1-30**]. Seen by SLP [**1-31**] who\n', ' recommended above altered consistency diet with 1:1 supervision. [**Name8 (MD) **]\n', ' RN, patient took Ensure pudding and some Carnation Instant Breakfast\n', ' shake this AM with a lot of encouragement. Patient takes very small\n', ' bites and is a picky eater. RN reports wife to bring in a list of\n', ' foods that patient likes. Calorie counts starting today. Concerned\n', ' with nutrition status given poor po\n', 's during admit (refusing po\n', 's at\n', ' times), only received tube feed briefly on/off and recent surgery.\n', ' Would strongly recommend supplemental tube feed to optimize nutrition\n', ' for post-op recovery.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Current diet / nutrition support is appropriate:\n', ' Encourage/assist with po\n', ' o Encourage wife to bring in food preference list or food\n', ' o Calorie counts\n', ' please record on kitchen receipt percent\n', ' eaten\n', ' Oral supplements: Continue as ordered\n', ' Multivitamin / Mineral supplement: continue current\n', ' Tube feeding recommendations:\n', ' o Consider placing NGT and beginning tube feeds to supplement\n', ' poor po\n', ' o Tube feed goal would be: Nutren Pulmonary @ 45ml/hr = 1620\n', ' calories and 73g protein\n', ' Check chemistry 10 panel daily\n', ' Will follow, page if questions *[**Numeric Identifier 606**]\n', '"\n', '40461,Nutrition,"Subjective\n', ' just extubated\n', ' Objective\n', ' Height\n', ' Admit weight\n', ' Daily weight\n', ' Weight change\n', ' BMI\n', ' 178 cm\n', ' 63 kg\n', ' 76.2 kg ([**2113-1-30**] 04:00 AM)\n', ' 19.9\n', ' Pertinent medications: Multivitamins, others noted\n', ' Labs:\n', ' Value\n', ' Date\n', ' Glucose\n', ' 106 mg/dL\n', ' [**2113-1-30**] 07:59 AM\n', ' Glucose Finger Stick\n', ' 93\n', ' [**2113-1-29**] 06:00 PM\n', ' BUN\n', ' 20 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Creatinine\n', ' 1.6 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Sodium\n', ' 137 mEq/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Potassium\n', ' 3.5 mEq/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Chloride\n', ' 104 mEq/L\n', ' [**2113-1-30**] 03:25 AM\n', ' TCO2\n', ' 22 mEq/L\n', ' [**2113-1-30**] 03:25 AM\n', ' PO2 (arterial)\n', ' 85.[**Numeric Identifier 299**] mm Hg\n', ' [**2113-1-30**] 09:19 AM\n', ' PO2 (venous)\n', ' 48 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' PCO2 (arterial)\n', ' 33 mm Hg\n', ' [**2113-1-30**] 09:19 AM\n', ' PCO2 (venous)\n', ' 33 mm Hg\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (arterial)\n', ' 7.41 units\n', ' [**2113-1-30**] 09:19 AM\n', ' pH (venous)\n', ' 7.43 units\n', ' [**2113-1-21**] 05:21 PM\n', ' pH (urine)\n', ' 5.0 units\n', ' [**2113-1-25**] 02:26 PM\n', ' CO2 (Calc) arterial\n', ' 22 mEq/L\n', ' [**2113-1-30**] 09:19 AM\n', ' CO2 (Calc) venous\n', ' 23 mEq/L\n', ' [**2113-1-21**] 05:21 PM\n', ' Albumin\n', ' 2.2 g/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Calcium non-ionized\n', ' 8.4 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Phosphorus\n', ' 5.2 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Ionized Calcium\n', ' 1.09 mmol/L\n', ' [**2113-1-30**] 07:59 AM\n', ' Magnesium\n', ' 2.1 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' ALT\n', ' 20 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Alkaline Phosphate\n', ' 57 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' AST\n', ' 26 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Amylase\n', ' 17 IU/L\n', ' [**2113-1-30**] 03:25 AM\n', ' Total Bilirubin\n', ' 0.4 mg/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Triglyceride\n', ' 120 mg/dL\n', ' [**2113-1-25**] 03:36 AM\n', ' WBC\n', ' 11.5 K/uL\n', ' [**2113-1-30**] 03:25 AM\n', ' Hgb\n', ' 10.3 g/dL\n', ' [**2113-1-30**] 03:25 AM\n', ' Hematocrit\n', ' 30.1 %\n', ' [**2113-1-30**] 03:25 AM\n', ' Current diet order / nutrition support: Nutren Pulmonary Full strength;\n', ' Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr\n', ' Residual Check: q4h Hold feeding for residual >= : 200 ml\n', ' Flush w/ 30 ml water q4h ( not running)\n', ' GI: soft, flesiseal in place\n', ' SKIN: stage 2 wounds\n', ' Assessment of Nutritional Status\n', ' 49 year old male admitted on [**1-15**] with endocarditis s/p MVR and aortic\n', ' valve debridement on [**1-27**], patient extubated this morning. Patient\n', ' well known to me from CCU, patient with minimal nutrition since\n', ' hospital admission (previously refused po food and nutrition\n', ' supplements in the ccu, received 1 day of tube feed prior to OR.\n', ' Patient at very high risk for malnutrition, highly recommend replace\n', ' feeding tube, restart tube feed as temporary nutrition support for post\n', ' op recovery.\n', ' Medical Nutrition Therapy Plan - Recommend the Following\n', ' Adv diet if remains medically stable\n', ' Continue tube feed as supplemental nutrition support: goal\n', ' Nutren Pulmonary goal 45ml/hr to provide 1620kcal/73.4g protein\n', ' Phos binder if serum phos remains elevated\n', ' Check chemistry 10 panel daily, replete prn\n', ' BS management\n', ' Other: [**Numeric Identifier 943**]\n', '"\n'] 2136
In [41]:
for i in range(len(notes)):
print(notes[i])
print("*************************************************************************************")
SUBJECT_ID,CATEGORY,TEXT
*************************************************************************************
17610,Nutrition,"Patient transferred to MICU for concern for aspiration. Diet changed
*************************************************************************************
to NPO; NGT in for medication. Noted plan to transition to comfort
*************************************************************************************
focused care.
*************************************************************************************
Will sign off at this time. Please consult if needed. Pager *[**Numeric Identifier 5307**]
*************************************************************************************
"
*************************************************************************************
40493,Nutrition,"Objective
*************************************************************************************
Pertinent medications: RISS, SS lytes, thiamin, folate, lasix, bowel
*************************************************************************************
regimen, MOM, reglan, others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
93 mg/dL
*************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
120
*************************************************************************************
[**2172-11-9**] 08:57 AM
*************************************************************************************
BUN
*************************************************************************************
15 mg/dL
*************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************
Creatinine
*************************************************************************************
0.6 mg/dL
*************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************
Sodium
*************************************************************************************
137 mEq/L
*************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************
Potassium
*************************************************************************************
3.9 mEq/L
*************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************
Chloride
*************************************************************************************
106 mEq/L
*************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************
TCO2
*************************************************************************************
24 mEq/L
*************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
66 mm Hg
*************************************************************************************
[**2172-11-9**] 08:57 AM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
41 mm Hg
*************************************************************************************
[**2172-11-9**] 08:57 AM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.42 units
*************************************************************************************
[**2172-11-9**] 08:57 AM
*************************************************************************************
pH (urine)
*************************************************************************************
5.0 units
*************************************************************************************
[**2172-11-1**] 06:06 PM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
28 mEq/L
*************************************************************************************
[**2172-11-9**] 08:57 AM
*************************************************************************************
Albumin
*************************************************************************************
2.6 g/dL
*************************************************************************************
[**2172-11-3**] 02:24 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
8.7 mg/dL
*************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************
Phosphorus
*************************************************************************************
4.5 mg/dL
*************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************
Ionized Calcium
*************************************************************************************
1.11 mmol/L
*************************************************************************************
[**2172-11-5**] 01:34 PM
*************************************************************************************
Magnesium
*************************************************************************************
2.2 mg/dL
*************************************************************************************
[**2172-11-9**] 01:50 AM
*************************************************************************************
Current diet order / nutrition support: Fibersource HN@60mL/hr (1728
*************************************************************************************
kcals/73 gr aa) not infusing
*************************************************************************************
GI: Abd soft/+bs
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
Specifics:
*************************************************************************************
Pt extubated earlier today. Pt was previously tolerating TF
*************************************************************************************
s @ goal,
*************************************************************************************
meeting 100% estimated nutrition needs. Anticipate diet advancement as
*************************************************************************************
able.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
Advance diet per team c/ swallow eval if pt shows s/s of aspiration and
*************************************************************************************
advance diet per SLP- vs place NGT and resume TF's if unable to take
*************************************************************************************
po
*************************************************************************************
Will follow plan -please page c/ ?'s #[**Numeric Identifier 1684**]
*************************************************************************************
"
*************************************************************************************
40493,Nutrition,"Subjective
*************************************************************************************
intubated
*************************************************************************************
Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
168 cm
*************************************************************************************
65 kg
*************************************************************************************
23.1
*************************************************************************************
Ideal body weight
*************************************************************************************
% Ideal body weight
*************************************************************************************
Adjusted weight
*************************************************************************************
Usual body weight
*************************************************************************************
% Usual body weight
*************************************************************************************
64.4 kg
*************************************************************************************
101%
*************************************************************************************
Diagnosis: S/P Fall
*************************************************************************************
PMH : etoh, smoker, cirrhosis
*************************************************************************************
Food allergies and intolerances: NKFA
*************************************************************************************
Pertinent medications: fentanyl, LR @ 10 ml/hr, lasix, versed, RISS, IV
*************************************************************************************
abx, others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
155 mg/dL
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
151
*************************************************************************************
[**2172-11-2**] 08:00 AM
*************************************************************************************
BUN
*************************************************************************************
17 mg/dL
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Creatinine
*************************************************************************************
0.8 mg/dL
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Sodium
*************************************************************************************
146 mEq/L
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Potassium
*************************************************************************************
3.6 mEq/L
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Chloride
*************************************************************************************
111 mEq/L
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
TCO2
*************************************************************************************
29 mEq/L
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
113 mm Hg
*************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
41 mm Hg
*************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.46 units
*************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************
pH (urine)
*************************************************************************************
5.0 units
*************************************************************************************
[**2172-11-1**] 06:06 PM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
30 mEq/L
*************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************
Albumin
*************************************************************************************
3.0 g/dL
*************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
8.1 mg/dL
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Phosphorus
*************************************************************************************
2.5 mg/dL
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Ionized Calcium
*************************************************************************************
1.16 mmol/L
*************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************
Magnesium
*************************************************************************************
1.7 mg/dL
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
ALT
*************************************************************************************
14 IU/L
*************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************
Alkaline Phosphate
*************************************************************************************
73 IU/L
*************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************
AST
*************************************************************************************
43 IU/L
*************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************
Total Bilirubin
*************************************************************************************
3.4 mg/dL
*************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************
WBC
*************************************************************************************
23.2 K/uL
*************************************************************************************
[**2172-11-2**] 01:06 AM
*************************************************************************************
Hgb
*************************************************************************************
9.1 g/dL
*************************************************************************************
[**2172-11-2**] 01:06 AM
*************************************************************************************
Hematocrit
*************************************************************************************
27.2 %
*************************************************************************************
[**2172-11-2**] 01:06 AM
*************************************************************************************
Current diet order / nutrition support: NPO replete with fiber @ 60
*************************************************************************************
ml/hr
*************************************************************************************
GI: OGT
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
At risk for malnutrition
*************************************************************************************
Pt at risk due to: NPO / hypocaloric diet
*************************************************************************************
Estimated Nutritional Needs
*************************************************************************************
Calories: 1625-[**2114**] (25-30 cal/kg)
*************************************************************************************
Protein: 78-91 (1.2-1.4 g/kg)
*************************************************************************************
Fluid: per team
*************************************************************************************
Estimation of previous intake: Likely Adequate
*************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************
Specifics: 57 year old male transferred from OSH, intubated there. Pt
*************************************************************************************
S/P fall CT shows Stage IV splenic laceration. Tolerating TF with
*************************************************************************************
minimal residuals [**Name8 (MD) **] RN. Current TF provides 1440 kcals/89 g Pro.
*************************************************************************************
Recommend changing TF to better meet nutritional needs.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
1. Check chemistry 10 panel daily
*************************************************************************************
2. Change TF to goal of Fibersource HN @ 65ml/hr (1872 kcals/83 g
*************************************************************************************
Pro)
*************************************************************************************
3. Pls page with questions [**Numeric Identifier 2584**]
*************************************************************************************
"
*************************************************************************************
40493,Nutrition,"Subjective
*************************************************************************************
intubated
*************************************************************************************
Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
168 cm
*************************************************************************************
65 kg
*************************************************************************************
23.1
*************************************************************************************
Ideal body weight
*************************************************************************************
% Ideal body weight
*************************************************************************************
Adjusted weight
*************************************************************************************
Usual body weight
*************************************************************************************
% Usual body weight
*************************************************************************************
64.4 kg
*************************************************************************************
101%
*************************************************************************************
Diagnosis: S/P Fall
*************************************************************************************
PMH : etoh, smoker, cirrhosis
*************************************************************************************
Food allergies and intolerances: NKFA
*************************************************************************************
Pertinent medications: fentanyl, LR @ 10 ml/hr, lasix, versed, RISS, IV
*************************************************************************************
abx, others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
155 mg/dL
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
151
*************************************************************************************
[**2172-11-2**] 08:00 AM
*************************************************************************************
BUN
*************************************************************************************
17 mg/dL
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Creatinine
*************************************************************************************
0.8 mg/dL
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Sodium
*************************************************************************************
146 mEq/L
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Potassium
*************************************************************************************
3.6 mEq/L
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Chloride
*************************************************************************************
111 mEq/L
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
TCO2
*************************************************************************************
29 mEq/L
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
113 mm Hg
*************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
41 mm Hg
*************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.46 units
*************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************
pH (urine)
*************************************************************************************
5.0 units
*************************************************************************************
[**2172-11-1**] 06:06 PM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
30 mEq/L
*************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************
Albumin
*************************************************************************************
3.0 g/dL
*************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
8.1 mg/dL
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Phosphorus
*************************************************************************************
2.5 mg/dL
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
Ionized Calcium
*************************************************************************************
1.16 mmol/L
*************************************************************************************
[**2172-11-2**] 11:55 AM
*************************************************************************************
Magnesium
*************************************************************************************
1.7 mg/dL
*************************************************************************************
[**2172-11-2**] 12:18 PM
*************************************************************************************
ALT
*************************************************************************************
14 IU/L
*************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************
Alkaline Phosphate
*************************************************************************************
73 IU/L
*************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************
AST
*************************************************************************************
43 IU/L
*************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************
Total Bilirubin
*************************************************************************************
3.4 mg/dL
*************************************************************************************
[**2172-10-31**] 02:55 AM
*************************************************************************************
WBC
*************************************************************************************
23.2 K/uL
*************************************************************************************
[**2172-11-2**] 01:06 AM
*************************************************************************************
Hgb
*************************************************************************************
9.1 g/dL
*************************************************************************************
[**2172-11-2**] 01:06 AM
*************************************************************************************
Hematocrit
*************************************************************************************
27.2 %
*************************************************************************************
[**2172-11-2**] 01:06 AM
*************************************************************************************
Current diet order / nutrition support: NPO replete with fiber @ 60
*************************************************************************************
ml/hr
*************************************************************************************
GI: OGT
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
At risk for malnutrition
*************************************************************************************
Pt at risk due to: NPO / hypocaloric diet
*************************************************************************************
Estimated Nutritional Needs
*************************************************************************************
Calories: 1625-[**2114**] (25-30 cal/kg)
*************************************************************************************
Protein: 78-91 (1.2-1.4 g/kg)
*************************************************************************************
Fluid: per team
*************************************************************************************
Estimation of previous intake: Likely Adequate
*************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************
Specifics: 57 year old male transferred from OSH, intubated there. Pt
*************************************************************************************
S/P fall CT shows Stage IV splenic laceration. Tolerating TF with
*************************************************************************************
minimal residuals [**Name8 (MD) **] RN. Current TF provides 1440 kcals/89 g Pro.
*************************************************************************************
Recommend changing TF to better meet nutritional needs.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
1. Check chemistry 10 panel daily
*************************************************************************************
2. Change TF to goal of Fibersource HN @ 65ml/hr (1872 kcals/83 g
*************************************************************************************
Pro)
*************************************************************************************
3. Pls page with questions [**Numeric Identifier 2584**]
*************************************************************************************
"
*************************************************************************************
61565,Nutrition,"Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
178 cm
*************************************************************************************
88.2 kg
*************************************************************************************
27.8
*************************************************************************************
Ideal body weight
*************************************************************************************
% Ideal body weight
*************************************************************************************
Adjusted weight
*************************************************************************************
Usual body weight
*************************************************************************************
% Usual body weight
*************************************************************************************
75.3 kg
*************************************************************************************
117%
*************************************************************************************
Diagnosis: Head Bleed
*************************************************************************************
PMH : DM.
*************************************************************************************
Food allergies and intolerances:
*************************************************************************************
Pertinent medications: Esmolol, famotidine, colace, lytes ss, dilantin,
*************************************************************************************
ssri, others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
143 mg/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
155
*************************************************************************************
[**2100-11-1**] 02:00 AM
*************************************************************************************
BUN
*************************************************************************************
18 mg/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Creatinine
*************************************************************************************
0.8 mg/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Sodium
*************************************************************************************
142 mEq/L
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Potassium
*************************************************************************************
4.1 mEq/L
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Chloride
*************************************************************************************
111 mEq/L
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
TCO2
*************************************************************************************
26 mEq/L
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
109 mm Hg
*************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
38 mm Hg
*************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.48 units
*************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
29 mEq/L
*************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************
Albumin
*************************************************************************************
3.8 g/dL
*************************************************************************************
[**2100-10-30**] 03:27 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
8.9 mg/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Phosphorus
*************************************************************************************
2.5 mg/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Ionized Calcium
*************************************************************************************
1.22 mmol/L
*************************************************************************************
[**2100-10-31**] 02:41 AM
*************************************************************************************
Magnesium
*************************************************************************************
2.3 mg/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Phenytoin (Dilantin)
*************************************************************************************
10.1 ug/mL
*************************************************************************************
[**2100-10-31**] 02:34 AM
*************************************************************************************
WBC
*************************************************************************************
12.1 K/uL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Hgb
*************************************************************************************
11.9 g/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Hematocrit
*************************************************************************************
33.9 %
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Current diet order / nutrition support: Replete with fiber Full
*************************************************************************************
strength; Goal rate: 65 ml/hr
*************************************************************************************
Residual Check: q4h Hold feeding for residual >= : 200 ml
*************************************************************************************
GI:
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
At risk for malnutrition
*************************************************************************************
Pt at risk due to: NPO / hypocaloric diet
*************************************************************************************
Estimated Nutritional Needs
*************************************************************************************
Calories: [**2027**]-2200 (BEE x or / 22-25 cal/kg)
*************************************************************************************
Protein: 114 (1.3 g/kg)
*************************************************************************************
Fluid:
*************************************************************************************
Estimation of previous intake: Adequate
*************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************
Specifics:
*************************************************************************************
72 yo male s/p witnessed fall w/ head trauma, right parietal-occipital
*************************************************************************************
SAH w/ left intraparenchymal bleed / contre-coup injury. Pt started on
*************************************************************************************
TF yesterday, currently tol goal TF without issue, per chart, pt with +
*************************************************************************************
gag, will plan to extubate this am. If unable to extubate, will need
*************************************************************************************
to change TF to better meet pt's needs.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
Tube feeding recommendations:
*************************************************************************************
Check chemistry 10 panel daily and replete
*************************************************************************************
Cont Bg management
*************************************************************************************
Pplease page [**Numeric Identifier 1550**] if has ?
*************************************************************************************
"
*************************************************************************************
61565,Nutrition,"Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
178 cm est.
*************************************************************************************
88.2 kg
*************************************************************************************
27.8
*************************************************************************************
Ideal body weight
*************************************************************************************
% Ideal body weight
*************************************************************************************
Adjusted weight
*************************************************************************************
Usual body weight
*************************************************************************************
% Usual body weight
*************************************************************************************
75.3 kg
*************************************************************************************
117%
*************************************************************************************
Diagnosis: Head Bleed
*************************************************************************************
PMH : DM, HTN
*************************************************************************************
Food allergies and intolerances:
*************************************************************************************
Pertinent medications: Esmolol, famotidine, colace, lytes ss, dilantin,
*************************************************************************************
ssri, others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
143 mg/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
155
*************************************************************************************
[**2100-11-1**] 02:00 AM
*************************************************************************************
BUN
*************************************************************************************
18 mg/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Creatinine
*************************************************************************************
0.8 mg/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Sodium
*************************************************************************************
142 mEq/L
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Potassium
*************************************************************************************
4.1 mEq/L
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Chloride
*************************************************************************************
111 mEq/L
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
TCO2
*************************************************************************************
26 mEq/L
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
109 mm Hg
*************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
38 mm Hg
*************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.48 units
*************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
29 mEq/L
*************************************************************************************
[**2100-11-1**] 04:35 AM
*************************************************************************************
Albumin
*************************************************************************************
3.8 g/dL
*************************************************************************************
[**2100-10-30**] 03:27 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
8.9 mg/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Phosphorus
*************************************************************************************
2.5 mg/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Ionized Calcium
*************************************************************************************
1.22 mmol/L
*************************************************************************************
[**2100-10-31**] 02:41 AM
*************************************************************************************
Magnesium
*************************************************************************************
2.3 mg/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Phenytoin (Dilantin)
*************************************************************************************
10.1 ug/mL
*************************************************************************************
[**2100-10-31**] 02:34 AM
*************************************************************************************
WBC
*************************************************************************************
12.1 K/uL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Hgb
*************************************************************************************
11.9 g/dL
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Hematocrit
*************************************************************************************
33.9 %
*************************************************************************************
[**2100-11-1**] 02:37 AM
*************************************************************************************
Current diet order / nutrition support: Replete with fiber Full
*************************************************************************************
strength; Goal rate: 65 ml/hr (1560kcal/96.7g pro)
*************************************************************************************
Residual Check: q4h Hold feeding for residual >= : 200 ml
*************************************************************************************
GI: Soft, Non-distended, Non-tender
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
At risk for malnutrition
*************************************************************************************
Pt at risk due to: NPO
*************************************************************************************
Estimated Nutritional Needs
*************************************************************************************
Calories: 1760-2200 (BEE x or / 20-25 cal/kg)
*************************************************************************************
Protein: 114 (1.3 g/kg)
*************************************************************************************
Fluid: per team
*************************************************************************************
Estimation of previous intake: likely adequate
*************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************
Specifics:
*************************************************************************************
72 yo male s/p witnessed fall w/ head trauma, right parietal-occipital
*************************************************************************************
SAH w/ left intraparenchymal bleed / contre-coup injury. Pt started on
*************************************************************************************
TF yesterday, currently tol goal TF without issue, per chart, pt with +
*************************************************************************************
gag, cough, [**Last Name (LF) 1080**], [**First Name3 (LF) **] plan to extubate this am. If unable to
*************************************************************************************
extubate, will need to change TF to better meet pt's needs.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
Tube feeding recommendations: increase TF to Replete with Fiber goal
*************************************************************************************
75ml/hr (1800kcal/112g pro)
*************************************************************************************
Check chemistry 10 panel daily and replete prn
*************************************************************************************
Cont Bg management
*************************************************************************************
Please page [**Numeric Identifier 1550**] if has ?
*************************************************************************************
"
*************************************************************************************
61565,Nutrition,"Objective
*************************************************************************************
Pertinent medications: pepcid, Heparin, docusate, Abx, RISS, others
*************************************************************************************
noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
128 mg/dL
*************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
140
*************************************************************************************
[**2100-11-4**] 08:00 PM
*************************************************************************************
BUN
*************************************************************************************
18 mg/dL
*************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************
Creatinine
*************************************************************************************
0.7 mg/dL
*************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************
Sodium
*************************************************************************************
140 mEq/L
*************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************
Potassium
*************************************************************************************
3.9 mEq/L
*************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************
Chloride
*************************************************************************************
103 mEq/L
*************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************
TCO2
*************************************************************************************
28 mEq/L
*************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
94.[**Numeric Identifier 126**] mm Hg
*************************************************************************************
[**2100-11-5**] 07:26 AM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
37 mm Hg
*************************************************************************************
[**2100-11-5**] 07:26 AM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.49 units
*************************************************************************************
[**2100-11-5**] 07:26 AM
*************************************************************************************
pH (urine)
*************************************************************************************
7.0 units
*************************************************************************************
[**2100-11-5**] 11:05 AM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
29 mEq/L
*************************************************************************************
[**2100-11-5**] 07:26 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
8.7 mg/dL
*************************************************************************************
[**2100-11-4**] 02:31 AM
*************************************************************************************
Phosphorus
*************************************************************************************
3.0 mg/dL
*************************************************************************************
[**2100-11-4**] 02:31 AM
*************************************************************************************
Magnesium
*************************************************************************************
2.3 mg/dL
*************************************************************************************
[**2100-11-4**] 02:31 AM
*************************************************************************************
WBC
*************************************************************************************
12.2 K/uL
*************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************
Hgb
*************************************************************************************
12.0 g/dL
*************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************
Hematocrit
*************************************************************************************
33.8 %
*************************************************************************************
[**2100-11-5**] 03:32 AM
*************************************************************************************
Current diet order / nutrition support: Replete c/ Fiber @65mL/hr (1560
*************************************************************************************
kcals/97 gr aa)
*************************************************************************************
GI: Abd: soft/+bs
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************
Specifics:
*************************************************************************************
Pt s/p trach/PEG/and IVC filter yesterday. TF
*************************************************************************************
s currently infusing @
*************************************************************************************
10mL/hr. Current goal Rx will meet 88% estimated kcal and 85% estimated
*************************************************************************************
aa needs therefore, will need to increase goal rate of TF
*************************************************************************************
s to avoid
*************************************************************************************
underfeeding. .
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
Multivitamin / Mineral supplement: vua TF
*************************************************************************************
Tube feeding recommendations: Increase TF goal rate to 75 mL/hr (1800
*************************************************************************************
kcals/112 gr aa)
*************************************************************************************
BG management as you are
*************************************************************************************
Please page c/?'s #[**Numeric Identifier 1684**]
*************************************************************************************
"
*************************************************************************************
98851,Nutrition,"Patient has been NPO and/or on unsupplemented clear liquid diet for 1
*************************************************************************************
days. If patient's diet is not able to be advanced and tolerated,
*************************************************************************************
[**Street Address(1) 1511**] for nutrition support
*************************************************************************************
Potential for nutrition risk. Patient being monitored. Current
*************************************************************************************
intervention if any, listed below:
*************************************************************************************
Comments:
*************************************************************************************
Pt s/p LRRT [**4-17**], c/b hypoxia and increased O2 requirements in PACU, on
*************************************************************************************
clears, tolerating well. Clinically improving, possibly transfer to
*************************************************************************************
floor soon.
*************************************************************************************
If unable to advance diet further in 24-48hrs, patient may benefit from
*************************************************************************************
nutrition support.
*************************************************************************************
Will f/u with progress, po tolerance.
*************************************************************************************
Please page w/ questions #[**Numeric Identifier 1687**]
*************************************************************************************
12:11
*************************************************************************************
"
*************************************************************************************
58054,Nutrition,"Comments:
*************************************************************************************
Screening per hospital nutrition protocol. Noted patient is comfort
*************************************************************************************
measures only. No nutrition support indicated at this time. Will sign
*************************************************************************************
off. Please consult if needed. #[**Numeric Identifier 2337**]
*************************************************************************************
"
*************************************************************************************
99573,Nutrition,"Subjective
*************************************************************************************
patient confused, unable to answer questions per chart patient had
*************************************************************************************
difficulty swallowing PTA d/t damaged salivary glands from XRT
*************************************************************************************
Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
168 cm
*************************************************************************************
98.2 kg
*************************************************************************************
34.9
*************************************************************************************
Ideal body weight
*************************************************************************************
% Ideal body weight
*************************************************************************************
Adjusted weight
*************************************************************************************
Usual body weight
*************************************************************************************
% Usual body weight
*************************************************************************************
59 kg
*************************************************************************************
166%
*************************************************************************************
68.8 kg
*************************************************************************************
Diagnosis: facial fx
*************************************************************************************
PMH : breast ca, tongue ca, ovarian ca, polymyalgia, NIDDM, vertigo, hx
*************************************************************************************
of falls
*************************************************************************************
Food allergies and intolerances: none noted
*************************************************************************************
Pertinent medications: RISS, IV abx, protonix, KCl (30 mEq), Dextrose
*************************************************************************************
5% 1/2 normal saline with KCl, others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
206
*************************************************************************************
[**2181-6-5**] 08:00 AM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
222
*************************************************************************************
[**2181-6-4**] 08:00 PM
*************************************************************************************
BUN
*************************************************************************************
11 mg/dL
*************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************
Creatinine
*************************************************************************************
0.5 mg/dL
*************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************
Sodium
*************************************************************************************
134 mEq/L
*************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************
Potassium
*************************************************************************************
4.1 mEq/L
*************************************************************************************
[**2181-6-5**] 09:13 AM
*************************************************************************************
Chloride
*************************************************************************************
98 mEq/L
*************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************
TCO2
*************************************************************************************
26 mEq/L
*************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************
pH (urine)
*************************************************************************************
6.5 units
*************************************************************************************
[**2181-6-3**] 12:30 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
8.5 mg/dL
*************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************
Phosphorus
*************************************************************************************
2.3 mg/dL
*************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************
Magnesium
*************************************************************************************
2.0 mg/dL
*************************************************************************************
[**2181-6-4**] 11:36 PM
*************************************************************************************
WBC
*************************************************************************************
9.2 K/uL
*************************************************************************************
[**2181-6-5**] 12:03 AM
*************************************************************************************
Hgb
*************************************************************************************
10.9 g/dL
*************************************************************************************
[**2181-6-5**] 12:03 AM
*************************************************************************************
Hematocrit
*************************************************************************************
32.7 %
*************************************************************************************
[**2181-6-5**] 12:03 AM
*************************************************************************************
Current diet order / nutrition support: NPO
*************************************************************************************
GI: obese, + bowel sounds
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
Obese, At risk for malnutrition
*************************************************************************************
Pt at risk due to: NPO / hypocaloric diet, trauma
*************************************************************************************
Estimated Nutritional Needs based on adjusted body wt
*************************************************************************************
Calories: 1513-1720 (22-25 cal/kg)
*************************************************************************************
Protein: 83-103 (1.2-1.5 g/kg)
*************************************************************************************
Fluid: per team
*************************************************************************************
Estimation of previous intake: unknown
*************************************************************************************
Estimation of current intake: Inadequate d/t NPO status
*************************************************************************************
Specifics: 78 year old female admitted from outside hospital S/P fall
*************************************************************************************
at home with multiple injuries including Le Forte fx, multiple sinus
*************************************************************************************
fx, orbital fx, facial and tongue swelling. Patient seen by SLP on [**6-4**]
*************************************************************************************
who recommended patient remain NPO. If patient
*************************************************************************************
s diet cannot be
*************************************************************************************
advanced consider initiating tube feedings to prevent further
*************************************************************************************
nutritional decline.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
If diet cannot be advanced recommend starting tube feedings start with
*************************************************************************************
Replete with Fiber @ 15 ml/hr advance to goal of 65 ml/hr =1560
*************************************************************************************
kcals/97 g protein
*************************************************************************************
Check residuals q 4-6 hours hold if greater than 150 cc
*************************************************************************************
Monitor lytes and glucose with initiation of tube feeding
*************************************************************************************
Change to non-dextrose IV fluids once tube feedings started
*************************************************************************************
Implement any SLP recs
*************************************************************************************
Will continue to follow page [**Numeric Identifier 1372**] with questions
*************************************************************************************
"
*************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************
oriented x1
*************************************************************************************
Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
178 cm
*************************************************************************************
63 kg
*************************************************************************************
74.9 kg ([**2113-2-3**] 04:00 AM)
*************************************************************************************
19.9
*************************************************************************************
Pertinent medications: Ranitidine, Multi-vitamin, ABX, Folic Acid,
*************************************************************************************
Thiamine, Coumadin, Lasix, Colace (held), KCl (20mEq repletion x2),
*************************************************************************************
Magnesium sulfate (2g repletion), Heparin drip
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
105 mg/dL
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
127
*************************************************************************************
[**2113-2-3**] 12:00 PM
*************************************************************************************
BUN
*************************************************************************************
25 mg/dL
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Creatinine
*************************************************************************************
1.8 mg/dL
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Sodium
*************************************************************************************
142 mEq/L
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Potassium
*************************************************************************************
3.9 mEq/L
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Chloride
*************************************************************************************
110 mEq/L
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
TCO2
*************************************************************************************
25 mEq/L
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
65 mm Hg
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
PO2 (venous)
*************************************************************************************
48 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
30 mm Hg
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
PCO2 (venous)
*************************************************************************************
33 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.46 units
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
pH (venous)
*************************************************************************************
7.43 units
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (urine)
*************************************************************************************
5.5 units
*************************************************************************************
[**2113-2-1**] 07:16 AM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
22 mEq/L
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
CO2 (Calc) venous
*************************************************************************************
23 mEq/L
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
Albumin
*************************************************************************************
2.1 g/dL
*************************************************************************************
[**2113-2-1**] 02:44 PM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
7.5 mg/dL
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Phosphorus
*************************************************************************************
3.0 mg/dL
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Ionized Calcium
*************************************************************************************
1.08 mmol/L
*************************************************************************************
[**2113-1-30**] 11:46 AM
*************************************************************************************
Magnesium
*************************************************************************************
2.3 mg/dL
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
ALT
*************************************************************************************
23 IU/L
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Alkaline Phosphate
*************************************************************************************
51 IU/L
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
AST
*************************************************************************************
24 IU/L
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Amylase
*************************************************************************************
40 IU/L
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Total Bilirubin
*************************************************************************************
0.3 mg/dL
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Triglyceride
*************************************************************************************
120 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
WBC
*************************************************************************************
9.3 K/uL
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Hgb
*************************************************************************************
8.9 g/dL
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Hematocrit
*************************************************************************************
27.0 %
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Current diet order / nutrition support: Diet: NPO
*************************************************************************************
Calorie counts: [**2-1**] - 17 - 18
*************************************************************************************
GI: soft, (+) bowel sounds; 500ml stool today
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************
Specifics:
*************************************************************************************
49 year old male with mitral valve endocarditis, preop stroke s/p MVR
*************************************************************************************
(29mm [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1104**] [**Last Name (NamePattern1) 1105**]) debridement of aortic valve [**1-27**]. Patient with
*************************************************************************************
prolonged poor po
*************************************************************************************
s during admit. Was on ground solids + thin liquid
*************************************************************************************
diet, refusing po
*************************************************************************************
s at times. s/p calories counts
*************************************************************************************
880 calories [**2-1**]
*************************************************************************************
and 270 calories [**2-2**]. Seen for video swallow evaluation this AM
*************************************************************************************
SLP recommend NPO. Per discussion with PA
*************************************************************************************
plan for PEG placement as
*************************************************************************************
previously unable to place NGT and feel that patient will pull it out.
*************************************************************************************
Agree with PEG for long term nutrition support to prevent further
*************************************************************************************
nutritional decline and optimize nutrition for post-op healing. Noted
*************************************************************************************
multiple lyte repletions.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
Current diet / nutrition support is appropriate: continue
*************************************************************************************
NPO per SLP recommendations
*************************************************************************************
o SLP follow up when appropriate
*************************************************************************************
Tube feeding recommendations: Agree with PEG
*************************************************************************************
o Once feeding tube placed, recommend begin Isosource 1.5 @
*************************************************************************************
20ml/hr, advance as tolerated to goal of 45ml/hr = 1620 calories and
*************************************************************************************
73g protein
*************************************************************************************
Check residuals, hold tube feed if greater than 200ml
*************************************************************************************
Multivitamin / Mineral supplement: continue current
*************************************************************************************
Check chemistry 10 panel daily
*************************************************************************************
o Replete lytes PRN
*************************************************************************************
Will follow, page if questions *[**Numeric Identifier 606**]
*************************************************************************************
"
*************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************
Patient oob, tube feed running at 40 ml/hr.
*************************************************************************************
Objective
*************************************************************************************
Pertinent medications: noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
119
*************************************************************************************
[**2113-2-8**] 08:00 AM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
150
*************************************************************************************
[**2113-2-7**] 10:00 PM
*************************************************************************************
BUN
*************************************************************************************
31 mg/dL
*************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************
Creatinine
*************************************************************************************
2.0 mg/dL
*************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************
Sodium
*************************************************************************************
143 mEq/L
*************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************
Potassium
*************************************************************************************
3.4 mEq/L
*************************************************************************************
[**2113-2-8**] 07:52 AM
*************************************************************************************
Chloride
*************************************************************************************
109 mEq/L
*************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************
TCO2
*************************************************************************************
25 mEq/L
*************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
65 mm Hg
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
PO2 (venous)
*************************************************************************************
48 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
30 mm Hg
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
PCO2 (venous)
*************************************************************************************
33 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.46 units
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
pH (venous)
*************************************************************************************
7.43 units
*************************************************************************************
[**2113-2-7**] 05:19 PM
*************************************************************************************
pH (urine)
*************************************************************************************
5.5 units
*************************************************************************************
[**2113-2-1**] 07:16 AM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
22 mEq/L
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
CO2 (Calc) venous
*************************************************************************************
23 mEq/L
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
Albumin
*************************************************************************************
2.2 g/dL
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
7.8 mg/dL
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Phosphorus
*************************************************************************************
4.0 mg/dL
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Ionized Calcium
*************************************************************************************
1.07 mmol/L
*************************************************************************************
[**2113-2-7**] 05:19 PM
*************************************************************************************
Magnesium
*************************************************************************************
2.1 mg/dL
*************************************************************************************
[**2113-2-8**] 07:52 AM
*************************************************************************************
ALT
*************************************************************************************
21 IU/L
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Alkaline Phosphate
*************************************************************************************
50 IU/L
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
AST
*************************************************************************************
23 IU/L
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Amylase
*************************************************************************************
45 IU/L
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Total Bilirubin
*************************************************************************************
0.4 mg/dL
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Triglyceride
*************************************************************************************
120 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
WBC
*************************************************************************************
10.1 K/uL
*************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************
Hgb
*************************************************************************************
8.3 g/dL
*************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************
Hematocrit
*************************************************************************************
26.1 %
*************************************************************************************
[**2113-2-8**] 02:50 AM
*************************************************************************************
Current diet order / nutrition support: Replete with fiber Full
*************************************************************************************
strength;
*************************************************************************************
Starting rate: 40 ml/hr; Advance rate by 20 ml q6h Goal rate: 70 ml/hr
*************************************************************************************
Residual Check: q4h Hold feeding for residual >= : 200 ml
*************************************************************************************
Flush w/ 30 ml water q8h
*************************************************************************************
GI: Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,
*************************************************************************************
PEG site clean and dry.
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
49 year old male s/p PEG placement yesterday, tube feed started
*************************************************************************************
yesterday, tolerated Isosource 1.5 well, tube feed ordered changed to
*************************************************************************************
Replete with fiber this morning, spoke to team, does not want patient
*************************************************************************************
on special tube feed, recommend change to Fibersource HN as current
*************************************************************************************
formula provides excess amount of protein. Noted discharge planning in
*************************************************************************************
progress.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
Tube feeding: Fibersource HN goal 60ml/hr ( 1728kcal/76g
*************************************************************************************
protein)
*************************************************************************************
Check chemistry 10 panel daily, replete prn
*************************************************************************************
Continue BS management
*************************************************************************************
[**Numeric Identifier 943**] if has question
*************************************************************************************
"
*************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************
Patient asleep.
*************************************************************************************
Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
178 cm
*************************************************************************************
63 kg
*************************************************************************************
70.8 kg ([**2113-2-7**] 04:00 AM)
*************************************************************************************
19.9
*************************************************************************************
Pertinent medications: Multiple Vitamins, Furosemide, Docusate Sodium,
*************************************************************************************
others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
157 mg/dL
*************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
158
*************************************************************************************
[**2113-2-7**] 06:00 AM
*************************************************************************************
BUN
*************************************************************************************
33 mg/dL
*************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************
Creatinine
*************************************************************************************
1.9 mg/dL
*************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************
Sodium
*************************************************************************************
145 mEq/L
*************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************
Potassium
*************************************************************************************
3.7 mEq/L
*************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************
Chloride
*************************************************************************************
111 mEq/L
*************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************
TCO2
*************************************************************************************
24 mEq/L
*************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
65 mm Hg
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
PO2 (venous)
*************************************************************************************
48 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
30 mm Hg
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
PCO2 (venous)
*************************************************************************************
33 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.46 units
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
pH (venous)
*************************************************************************************
7.43 units
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (urine)
*************************************************************************************
5.5 units
*************************************************************************************
[**2113-2-1**] 07:16 AM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
22 mEq/L
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
CO2 (Calc) venous
*************************************************************************************
23 mEq/L
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
Albumin
*************************************************************************************
2.2 g/dL
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
7.8 mg/dL
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Phosphorus
*************************************************************************************
4.0 mg/dL
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Ionized Calcium
*************************************************************************************
1.08 mmol/L
*************************************************************************************
[**2113-1-30**] 11:46 AM
*************************************************************************************
Magnesium
*************************************************************************************
2.0 mg/dL
*************************************************************************************
[**2113-2-6**] 11:00 PM
*************************************************************************************
ALT
*************************************************************************************
21 IU/L
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Alkaline Phosphate
*************************************************************************************
50 IU/L
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
AST
*************************************************************************************
23 IU/L
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Amylase
*************************************************************************************
45 IU/L
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Total Bilirubin
*************************************************************************************
0.4 mg/dL
*************************************************************************************
[**2113-2-6**] 04:05 AM
*************************************************************************************
Triglyceride
*************************************************************************************
120 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
WBC
*************************************************************************************
12.3 K/uL
*************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************
Hgb
*************************************************************************************
8.8 g/dL
*************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************
Hematocrit
*************************************************************************************
26.9 %
*************************************************************************************
[**2113-2-7**] 04:00 AM
*************************************************************************************
Current diet order / nutrition support: Non-Standard TPN For Date:
*************************************************************************************
[**2113-2-6**] (1600ml, 270drextrose/80protein/35fat)
*************************************************************************************
Replete with fiber Full strength;
*************************************************************************************
Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 60 ml/hr
*************************************************************************************
Residual Check: q4h Hold feeding for residual >= : 200 ml
*************************************************************************************
Flush w/ 30 ml water q8h
*************************************************************************************
GI: Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,
*************************************************************************************
PEG site clean and dry. Peg to gravity drainage
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
49 year old male with Mitral valve endocarditis, preop stroke s/p MVR
*************************************************************************************
and debridement of aortic valve [**1-27**], patient failed S & S evaluation,
*************************************************************************************
TPN started over the weekend while awaiting PEG. PEG placed
*************************************************************************************
yesterday, plan to start tube feeds today, current tube feed order not
*************************************************************************************
meeting patient
*************************************************************************************
s estimated need. Noted patient with post op fluid
*************************************************************************************
gain, recommend fluid restricted formula.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
Consider ordering day 1 TPN tonight while slowly advancing
*************************************************************************************
tube feed
*************************************************************************************
Tube feeding: Isosource 1.5cal goal 45ml/hr ( 1620kcal/73g
*************************************************************************************
protein)
*************************************************************************************
Start tube feed at 15ml/hr and adv slowly as tol
*************************************************************************************
Check chemistry 10 panel daily, replete prn
*************************************************************************************
Continue BS management
*************************************************************************************
[**Numeric Identifier 943**] if has question
*************************************************************************************
"
*************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************
patient sleeping
*************************************************************************************
Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
178 cm
*************************************************************************************
63 kg
*************************************************************************************
74.9 kg ([**2113-2-3**] 04:00 AM)
*************************************************************************************
19.9
*************************************************************************************
Pertinent medications: D5 @10 ml/hr, KCl (40 mEq repletion), RISS, IV
*************************************************************************************
abx, lansoprazole, famotidine, others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
73
*************************************************************************************
[**2113-2-4**] 12:00 PM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
135
*************************************************************************************
[**2113-2-4**] 12:00 AM
*************************************************************************************
BUN
*************************************************************************************
25 mg/dL
*************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************
Creatinine
*************************************************************************************
1.6 mg/dL
*************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************
Sodium
*************************************************************************************
140 mEq/L
*************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************
Potassium
*************************************************************************************
3.5 mEq/L
*************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************
Chloride
*************************************************************************************
108 mEq/L
*************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************
TCO2
*************************************************************************************
22 mEq/L
*************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
65 mm Hg
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
PO2 (venous)
*************************************************************************************
48 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
30 mm Hg
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
PCO2 (venous)
*************************************************************************************
33 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.46 units
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
pH (venous)
*************************************************************************************
7.43 units
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (urine)
*************************************************************************************
5.5 units
*************************************************************************************
[**2113-2-1**] 07:16 AM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
22 mEq/L
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
CO2 (Calc) venous
*************************************************************************************
23 mEq/L
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
Albumin
*************************************************************************************
2.1 g/dL
*************************************************************************************
[**2113-2-1**] 02:44 PM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
7.3 mg/dL
*************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************
Phosphorus
*************************************************************************************
3.1 mg/dL
*************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************
Ionized Calcium
*************************************************************************************
1.08 mmol/L
*************************************************************************************
[**2113-1-30**] 11:46 AM
*************************************************************************************
Magnesium
*************************************************************************************
2.0 mg/dL
*************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************
ALT
*************************************************************************************
23 IU/L
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Alkaline Phosphate
*************************************************************************************
51 IU/L
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
AST
*************************************************************************************
24 IU/L
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Amylase
*************************************************************************************
40 IU/L
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Total Bilirubin
*************************************************************************************
0.3 mg/dL
*************************************************************************************
[**2113-2-3**] 05:24 AM
*************************************************************************************
Triglyceride
*************************************************************************************
120 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
WBC
*************************************************************************************
13.4 K/uL
*************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************
Hgb
*************************************************************************************
9.8 g/dL
*************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************
Hematocrit
*************************************************************************************
29.7 %
*************************************************************************************
[**2113-2-4**] 03:42 AM
*************************************************************************************
Current diet order / nutrition support: NPO
*************************************************************************************
GI: soft, hypoactive bowel sounds
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
Specifics: Patient s/p video swallow [**2-3**] which recommended patient be
*************************************************************************************
NPO. Received consult for PPN recommendations. Per discussion with PA,
*************************************************************************************
plan is for PEG placement on Monday and to supplement nutrition with
*************************************************************************************
parenteral nutrition until PEG is able to be used. Patient with PICC,
*************************************************************************************
Day 1 TPN ordered to start tonight. NGT was attempted earlier in week
*************************************************************************************
and was unable to placed and team thinks patient would pull it out.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
1. Day 1 TPN tonight
*************************************************************************************
2. Pending glycemic control advance to goal TPN 1.6L (270 g
*************************************************************************************
dextrose/80 g amino acids/35 g lipids)= 1588 kcals
*************************************************************************************
3. Check TG hold lipids if greater than 400
*************************************************************************************
4. Once PEG placed start with Isosource HN @ 15 ml/hr advance to
*************************************************************************************
goal of 45 ml/hr = 1620 kcals/ 73 g protein
*************************************************************************************
5. Will follow page [**Numeric Identifier 1372**] with questions
*************************************************************************************
"
*************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************
Patient asleep, [**Name8 (MD) 77**] RN, patient refused all po food or supplements.
*************************************************************************************
Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
178 cm
*************************************************************************************
63 kg
*************************************************************************************
70.5 kg ([**2113-1-19**] 08:00 AM)
*************************************************************************************
up due to fluid
*************************************************************************************
19.9
*************************************************************************************
Ideal body weight
*************************************************************************************
% Ideal body weight
*************************************************************************************
Adjusted weight
*************************************************************************************
Usual body weight
*************************************************************************************
% Usual body weight
*************************************************************************************
75.3 kg
*************************************************************************************
119%
*************************************************************************************
63 kg
*************************************************************************************
100%
*************************************************************************************
Diagnosis: MITRAL VALVE ENDOCARDITIS
*************************************************************************************
PMHx: None - no medical care x 30 years
*************************************************************************************
Food allergies and intolerances: not available
*************************************************************************************
Pertinent medications: Furosemide , Milrinone, Multivitamins, Thiamine,
*************************************************************************************
FoLIC Acid, Nicotine Patch, Heparin, Docusate Sodium , Nafcillin,
*************************************************************************************
Potassium Chloride, others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
117 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
BUN
*************************************************************************************
25 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Creatinine
*************************************************************************************
1.5 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Sodium
*************************************************************************************
137 mEq/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Potassium
*************************************************************************************
3.3 mEq/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Chloride
*************************************************************************************
103 mEq/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
TCO2
*************************************************************************************
22 mEq/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
PO2 (venous)
*************************************************************************************
145 mm Hg
*************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************
PCO2 (venous)
*************************************************************************************
34 mm Hg
*************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************
pH (venous)
*************************************************************************************
7.45 units
*************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************
pH (urine)
*************************************************************************************
5.0 units
*************************************************************************************
[**2113-1-18**] 12:03 PM
*************************************************************************************
CO2 (Calc) venous
*************************************************************************************
24 mEq/L
*************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************
Albumin
*************************************************************************************
1.9 g/dL
*************************************************************************************
[**2113-1-18**] 07:15 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
7.1 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Phosphorus
*************************************************************************************
4.8 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Magnesium
*************************************************************************************
1.9 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
ALT
*************************************************************************************
36 IU/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Alkaline Phosphate
*************************************************************************************
44 IU/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
AST
*************************************************************************************
54 IU/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Total Bilirubin
*************************************************************************************
0.4 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
WBC
*************************************************************************************
13.0 K/uL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Hgb
*************************************************************************************
11.8 g/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Hematocrit
*************************************************************************************
35.2 %
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Current diet order / nutrition support: Regular; Supplement: Ensure
*************************************************************************************
Plus breakfast, lunch, dinner
*************************************************************************************
GI: Abdominal: Soft, Non-tender, Bowel sounds present
*************************************************************************************
Extremities: Right lower extremity edema: Absent, Left lower extremity
*************************************************************************************
edema
*************************************************************************************
Skin: Warm, Rash: upper and lower ext, occ petechiae
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
At risk for malnutrition
*************************************************************************************
Patient at risk due to: Low po intake, current illness, head CT showed multipl
*************************************************************************************
e small non-hemorrhagic
*************************************************************************************
infarcts suspicious for septic emboli,
*************************************************************************************
Estimated Nutritional Needs
*************************************************************************************
Calories: 1575-1764 (BEE x or / 25-28 cal/kg)
*************************************************************************************
Protein: 76-88 (1.2-1.4 g/kg)
*************************************************************************************
Fluid: per team
*************************************************************************************
Calculations based on: Admit weight
*************************************************************************************
Estimation of previous intake: Inadequate
*************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************
Specifics:
*************************************************************************************
49 year old male found to have staphylococcus aureus bacterial
*************************************************************************************
endocarditis with severe mitral regurgitation [**3-21**] mitral valve
*************************************************************************************
vegetations and flail leaflet. Patient transferred from [**Hospital **] [**Hospital1 5**] for CT surgery evaluation and further management.
*************************************************************************************
Patient s/p speech and swallow evaluation, okay to have regular diet,
*************************************************************************************
yet patient refused to take pos. spoke to team this morning, team
*************************************************************************************
considering NGT placement.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
Po as tolerance
*************************************************************************************
Tube feeding recommendations: Nutren Pulmonary goal 45ml/hr
*************************************************************************************
(1620kcal/73.4g protein)
*************************************************************************************
Monitor tube feed tolerance
*************************************************************************************
Check chemistry 10 panel daily, replete as you are doing
*************************************************************************************
Consider adding phos binder if serum phos remains elevated
*************************************************************************************
Start regular insulin sliding scale if serum glucose greater
*************************************************************************************
than 150 mg/dL
*************************************************************************************
Other: [**Numeric Identifier 943**] if has question
*************************************************************************************
"
*************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************
Patient asleep, [**Name8 (MD) 77**] RN, patient refused all po food or supplements.
*************************************************************************************
Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
178 cm
*************************************************************************************
63 kg
*************************************************************************************
70.5 kg ([**2113-1-19**] 08:00 AM)
*************************************************************************************
up due to fluid
*************************************************************************************
19.9
*************************************************************************************
Ideal body weight
*************************************************************************************
% Ideal body weight
*************************************************************************************
Adjusted weight
*************************************************************************************
Usual body weight
*************************************************************************************
% Usual body weight
*************************************************************************************
75.3 kg
*************************************************************************************
119%
*************************************************************************************
63 kg
*************************************************************************************
100%
*************************************************************************************
Diagnosis: MITRAL VALVE ENDOCARDITIS
*************************************************************************************
PMHx: None - no medical care x 30 years
*************************************************************************************
Food allergies and intolerances: not available
*************************************************************************************
Pertinent medications: Furosemide , Milrinone, Multivitamins, Thiamine,
*************************************************************************************
FoLIC Acid, Nicotine Patch, Heparin, Docusate Sodium , Nafcillin,
*************************************************************************************
Potassium Chloride, others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
117 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
BUN
*************************************************************************************
25 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Creatinine
*************************************************************************************
1.5 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Sodium
*************************************************************************************
137 mEq/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Potassium
*************************************************************************************
3.3 mEq/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Chloride
*************************************************************************************
103 mEq/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
TCO2
*************************************************************************************
22 mEq/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
PO2 (venous)
*************************************************************************************
145 mm Hg
*************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************
PCO2 (venous)
*************************************************************************************
34 mm Hg
*************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************
pH (venous)
*************************************************************************************
7.45 units
*************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************
pH (urine)
*************************************************************************************
5.0 units
*************************************************************************************
[**2113-1-18**] 12:03 PM
*************************************************************************************
CO2 (Calc) venous
*************************************************************************************
24 mEq/L
*************************************************************************************
[**2113-1-15**] 04:51 PM
*************************************************************************************
Albumin
*************************************************************************************
1.9 g/dL
*************************************************************************************
[**2113-1-18**] 07:15 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
7.1 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Phosphorus
*************************************************************************************
4.8 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Magnesium
*************************************************************************************
1.9 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
ALT
*************************************************************************************
36 IU/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Alkaline Phosphate
*************************************************************************************
44 IU/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
AST
*************************************************************************************
54 IU/L
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Total Bilirubin
*************************************************************************************
0.4 mg/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
WBC
*************************************************************************************
13.0 K/uL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Hgb
*************************************************************************************
11.8 g/dL
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Hematocrit
*************************************************************************************
35.2 %
*************************************************************************************
[**2113-1-20**] 02:36 AM
*************************************************************************************
Current diet order / nutrition support: Regular; Supplement: Ensure
*************************************************************************************
Plus breakfast, lunch, dinner
*************************************************************************************
GI: Abdominal: Soft, Non-tender, Bowel sounds present
*************************************************************************************
Extremities: Right lower extremity edema: Absent, Left lower extremity
*************************************************************************************
edema
*************************************************************************************
Skin: Warm, Rash: upper and lower ext, occ petechiae
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
At risk for malnutrition
*************************************************************************************
Patient at risk due to: Low po intake, current illness, head CT showed multipl
*************************************************************************************
e small non-hemorrhagic
*************************************************************************************
infarcts suspicious for septic emboli,
*************************************************************************************
Estimated Nutritional Needs
*************************************************************************************
Calories: 1575-1764 (BEE x or / 25-28 cal/kg)
*************************************************************************************
Protein: 76-88 (1.2-1.4 g/kg)
*************************************************************************************
Fluid: per team
*************************************************************************************
Calculations based on: Admit weight
*************************************************************************************
Estimation of previous intake: Inadequate
*************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************
Specifics:
*************************************************************************************
49 year old male found to have staphylococcus aureus bacterial
*************************************************************************************
endocarditis with severe mitral regurgitation [**3-21**] mitral valve
*************************************************************************************
vegetations and flail leaflet. Patient transferred from [**Hospital **] [**Hospital1 5**] for CT surgery evaluation and further management.
*************************************************************************************
Patient s/p speech and swallow evaluation, okay to have regular diet,
*************************************************************************************
yet patient refused to take pos. spoke to team this morning, team
*************************************************************************************
considering NGT placement.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
Po as tolerance
*************************************************************************************
Tube feeding recommendations: Nutren Pulmonary goal 45ml/hr
*************************************************************************************
(1620kcal/73.4g protein)
*************************************************************************************
Monitor tube feed tolerance
*************************************************************************************
Check chemistry 10 panel daily, replete as you are doing
*************************************************************************************
Consider adding phos binder if serum phos remains elevated
*************************************************************************************
Start regular insulin sliding scale if serum glucose greater
*************************************************************************************
than 150 mg/dL
*************************************************************************************
Other: [**Numeric Identifier 943**] if has question
*************************************************************************************
------ Protected Section ------
*************************************************************************************
Cardiology Teaching Physician Note
*************************************************************************************
On this day I saw, examined and was physically present with the
*************************************************************************************
resident / fellow for the key portions of the services provided. I
*************************************************************************************
agree with the above note and plans.
*************************************************************************************
I would add the following remarks:
*************************************************************************************
Medical Decision Making
*************************************************************************************
Patient slowly improving the am after aggressive diuresis and
*************************************************************************************
initiation of Milrinone. He is less dyspneic and saturations are in the
*************************************************************************************
95-96% range. Renal service feels ARF is multifactorial and sediment is
*************************************************************************************
c/w ATM. Createnine is stable today at 1.5. He is speaking clearly but
*************************************************************************************
somnolent and wife, [**Name (NI) 1880**], feels this is from not sleeping last night.
*************************************************************************************
WBC down to 13K from 14K yesterday. ID recommends continuing Nafcillin
*************************************************************************************
with bllod cultures with fever spikes. Source of fevers are unclear now
*************************************************************************************
and we may need to image his abdomen as he complains of intermittent
*************************************************************************************
abdominal pain. C-[**Doctor First Name 91**] continues to follow closely and would like to
*************************************************************************************
delay surgery for as long as possible.
*************************************************************************************
------ Protected Section Addendum Entered By:[**Name (NI) **] [**Last Name (NamePattern1) **], MD
*************************************************************************************
on:[**2113-1-20**] 05:48 PM ------
*************************************************************************************
"
*************************************************************************************
40461,Nutrition,"Subjective: Did not speak with patient.
*************************************************************************************
Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
178 cm
*************************************************************************************
63 kg
*************************************************************************************
72 kg ([**2113-1-22**] 10:00 AM)
*************************************************************************************
19.9
*************************************************************************************
Pertinent medications: Milrinone, protonix, abx, others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
98 mg/dL
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
BUN
*************************************************************************************
27 mg/dL
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Creatinine
*************************************************************************************
1.0 mg/dL
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Sodium
*************************************************************************************
137 mEq/L
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Potassium
*************************************************************************************
4.3 mEq/L
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Chloride
*************************************************************************************
107 mEq/L
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
TCO2
*************************************************************************************
19 mEq/L
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
61 mm Hg
*************************************************************************************
[**2113-1-22**] 12:22 AM
*************************************************************************************
PO2 (venous)
*************************************************************************************
48 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
31 mm Hg
*************************************************************************************
[**2113-1-22**] 12:22 AM
*************************************************************************************
PCO2 (venous)
*************************************************************************************
33 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.37 units
*************************************************************************************
[**2113-1-22**] 12:22 AM
*************************************************************************************
pH (venous)
*************************************************************************************
7.43 units
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (urine)
*************************************************************************************
5.0 units
*************************************************************************************
[**2113-1-20**] 06:24 PM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
19 mEq/L
*************************************************************************************
[**2113-1-22**] 12:22 AM
*************************************************************************************
CO2 (Calc) venous
*************************************************************************************
23 mEq/L
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
Albumin
*************************************************************************************
2.1 g/dL
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
7.6 mg/dL
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Phosphorus
*************************************************************************************
3.8 mg/dL
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Magnesium
*************************************************************************************
2.0 mg/dL
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
ALT
*************************************************************************************
27 IU/L
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Alkaline Phosphate
*************************************************************************************
50 IU/L
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
AST
*************************************************************************************
27 IU/L
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Total Bilirubin
*************************************************************************************
0.3 mg/dL
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
WBC
*************************************************************************************
20.7 K/uL
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Hgb
*************************************************************************************
12.9 g/dL
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Hematocrit
*************************************************************************************
39.5 %
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Current diet order / nutrition support: Diet: Regular/ heart healthy,
*************************************************************************************
with ensure plus TID
*************************************************************************************
GI: abd soft, bowel sounds present
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
49 year old male found to have staphylococcus aureus bacterial
*************************************************************************************
endocarditis with severe mitral regurgitation [**3-21**] mitral valve
*************************************************************************************
vegetations and flail leaflet. Patient transferred from [**Hospital **] to [**Hospital1 5**] for CT surgery evaluation and further management.
*************************************************************************************
Patient s/p speech and swallow evaluation, okay to have regular diet,
*************************************************************************************
yet patient is only taking small amounts of po
*************************************************************************************
s due to mental status.
*************************************************************************************
Team is planning to place an NGT for start of tube feeds. Tube
*************************************************************************************
feeding are recommendations below; these can be adjusted based on
*************************************************************************************
amount of po
*************************************************************************************
s patient is taking.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
To meet 100% of estimated needs, recommend Nutren Pulmonary
*************************************************************************************
@ 45mL/hr (1620kcals, 73g protein)
*************************************************************************************
Will monitor po intake and mental status and adjust tube
*************************************************************************************
feeds as needed.
*************************************************************************************
Following g- #[**Numeric Identifier 1312**]
*************************************************************************************
"
*************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************
intub
*************************************************************************************
Objective
*************************************************************************************
Pertinent medications: Multivitamins, FoLIC Acid , Pantoprazole,
*************************************************************************************
Potassium Chloride, Norepinephrine drip, others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
106 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
BUN
*************************************************************************************
15 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
Creatinine
*************************************************************************************
1.1 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
Sodium
*************************************************************************************
140 mEq/L
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
Potassium
*************************************************************************************
3.7 mEq/L
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
Chloride
*************************************************************************************
108 mEq/L
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
TCO2
*************************************************************************************
26 mEq/L
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
108 mm Hg
*************************************************************************************
[**2113-1-25**] 03:53 AM
*************************************************************************************
PO2 (venous)
*************************************************************************************
48 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
53 mm Hg
*************************************************************************************
[**2113-1-25**] 03:53 AM
*************************************************************************************
PCO2 (venous)
*************************************************************************************
33 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.32 units
*************************************************************************************
[**2113-1-25**] 03:53 AM
*************************************************************************************
pH (venous)
*************************************************************************************
7.43 units
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (urine)
*************************************************************************************
5.0 units
*************************************************************************************
[**2113-1-25**] 02:26 PM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
29 mEq/L
*************************************************************************************
[**2113-1-25**] 03:53 AM
*************************************************************************************
CO2 (Calc) venous
*************************************************************************************
23 mEq/L
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
Albumin
*************************************************************************************
2.1 g/dL
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
7.4 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
Phosphorus
*************************************************************************************
3.5 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
Magnesium
*************************************************************************************
1.6 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
ALT
*************************************************************************************
27 IU/L
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Alkaline Phosphate
*************************************************************************************
50 IU/L
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
AST
*************************************************************************************
27 IU/L
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Amylase
*************************************************************************************
25 IU/L
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Total Bilirubin
*************************************************************************************
0.3 mg/dL
*************************************************************************************
[**2113-1-22**] 05:17 AM
*************************************************************************************
Triglyceride
*************************************************************************************
120 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
WBC
*************************************************************************************
11.4 K/uL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
Hgb
*************************************************************************************
9.6 g/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
Hematocrit
*************************************************************************************
30.3 %
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
Current diet order / nutrition support: Nutren Pulmonary Full strength;
*************************************************************************************
Additives: Banana flakes, 3 packets per day
*************************************************************************************
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 45 ml/hr
*************************************************************************************
Residual Check: q4h Hold feeding for residual >= : 200 ml
*************************************************************************************
Flush w/ 100 ml water q8h ( not running since 8 am this morning)
*************************************************************************************
NPO for Procedure Start: After 12:01AM Procedure: CSURG on date
*************************************************************************************
[**2113-1-26**]
*************************************************************************************
Do NOT resume diet after procedure.
*************************************************************************************
GI: Abd: soft, ND, NT, NBS
*************************************************************************************
Ext: 2+ pulses, 2+ edema in lower extremtiies R>L
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
49 year old male found to have staphlyococcus aureus bacterial
*************************************************************************************
endocarditis with severe mitral regurgitation [**3-21**] mitral valve
*************************************************************************************
vegetations and flail leaflet, patient pending OR tomorrow for AVR and
*************************************************************************************
MVR with debridement of the epidural abscess. Patient received minimal
*************************************************************************************
nutrition since admission (had <24hours tube feed from 12/7-8), at very
*************************************************************************************
high risk for malnutrition, recommend closely monitor post cardiac
*************************************************************************************
surgery, may need to restart tube feed as patient was refusing all po
*************************************************************************************
food this admission.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
Multivitamin / Mineral supplement: discontinue outside order
*************************************************************************************
if tube feed restarts
*************************************************************************************
Tube feeding recommendations: restart tube feed as ordered
*************************************************************************************
Check chemistry 10 panel daily, replete as you are doing
*************************************************************************************
Start regular insulin sliding scale if serum glucose greater
*************************************************************************************
than 150 mg/dL
*************************************************************************************
Other: [**Numeric Identifier 943**] if has question
*************************************************************************************
"
*************************************************************************************
40461,Nutrition,"Ht: 70
*************************************************************************************
Wt: 57.8 kg
*************************************************************************************
IBW: 75.3 kg/ 77%
*************************************************************************************
BMI: 18.2
*************************************************************************************
Pmh: Diabetes,Dyslipidemia,Hypertension, [**1-25**] multiple embolic events
*************************************************************************************
worst is large left posterior cerebral artery infarct(neurologic
*************************************************************************************
deficits including left sided facial droop, right sided neglect, right
*************************************************************************************
sided hemiparesis, expressive aphasia),
*************************************************************************************
MVR(29mm St. [**Male First Name (un) 1104**] Mechanical Valve) with Debridement of Aortic Valve.
*************************************************************************************
Teeth extraction [**2113-1-23**].
*************************************************************************************
Diet Order: regular
*************************************************************************************
49 year old male was in rehab s/p M. Patient admitted to outside
*************************************************************************************
hospital CT showed depressed fx of right frontal sinus. Patient
*************************************************************************************
transferred
*************************************************************************************
Potential for nutrition risk. Patient being monitored. Current
*************************************************************************************
intervention if any, listed below:
*************************************************************************************
Comments:
*************************************************************************************
"
*************************************************************************************
40461,Nutrition,"Ht: 70
*************************************************************************************
Wt: 57.8 kg
*************************************************************************************
IBW: 75.3 kg/ 77%
*************************************************************************************
BMI: 18.2
*************************************************************************************
Pmh: Diabetes,Dyslipidemia,Hypertension, [**1-25**] multiple embolic events
*************************************************************************************
worst is large left posterior cerebral artery infarct(neurologic
*************************************************************************************
deficits including left sided facial droop, right sided neglect, right
*************************************************************************************
sided hemiparesis, expressive aphasia),
*************************************************************************************
MVR(29mm St. [**Male First Name (un) 1104**] Mechanical Valve) with Debridement of Aortic Valve.
*************************************************************************************
Teeth extraction [**2113-1-23**].
*************************************************************************************
Diet Order: regular
*************************************************************************************
49 year old male on coumadin for a prosthetic mitral valve after
*************************************************************************************
having Staphylococcal endocarditis of MV and AV, c/b multiple embolic
*************************************************************************************
strokes admitted from rehab s/p fall. Patient tolerating diet no nausea
*************************************************************************************
or vomiting. Patient reports much better po intake since admit to
*************************************************************************************
[**Hospital1 5**]. Patient unsure of wt loss PTA and unsure of usual body wt. Will
*************************************************************************************
add supplements to increase caloric intake.
*************************************************************************************
Recommendations:
*************************************************************************************
1. Encourage pos and supplements
*************************************************************************************
2. Will add ensure TID
*************************************************************************************
3. Will follow page [**Numeric Identifier 1372**] with questions
*************************************************************************************
"
*************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************
oriented x 1
*************************************************************************************
Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
178 cm
*************************************************************************************
63 kg
*************************************************************************************
72 kg ([**2113-2-1**] 04:00 AM)
*************************************************************************************
19.9
*************************************************************************************
Pertinent medications: Ranitidine, ABX, Folic Acid, Thiamine,
*************************************************************************************
Multi-vitamin, lasix, Colace (Held), KCl (20mEq repletion x3)
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
108 mg/dL
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
124
*************************************************************************************
[**2113-2-1**] 12:00 AM
*************************************************************************************
BUN
*************************************************************************************
28 mg/dL
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
Creatinine
*************************************************************************************
2.0 mg/dL
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
Sodium
*************************************************************************************
139 mEq/L
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
Potassium
*************************************************************************************
3.7 mEq/L
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
Chloride
*************************************************************************************
105 mEq/L
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
TCO2
*************************************************************************************
23 mEq/L
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
65 mm Hg
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
PO2 (venous)
*************************************************************************************
48 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
30 mm Hg
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
PCO2 (venous)
*************************************************************************************
33 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.46 units
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
pH (venous)
*************************************************************************************
7.43 units
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (urine)
*************************************************************************************
5.5 units
*************************************************************************************
[**2113-2-1**] 07:16 AM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
22 mEq/L
*************************************************************************************
[**2113-1-31**] 04:47 AM
*************************************************************************************
CO2 (Calc) venous
*************************************************************************************
23 mEq/L
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
Albumin
*************************************************************************************
2.2 g/dL
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
7.6 mg/dL
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
Phosphorus
*************************************************************************************
4.6 mg/dL
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
Ionized Calcium
*************************************************************************************
1.08 mmol/L
*************************************************************************************
[**2113-1-30**] 11:46 AM
*************************************************************************************
Magnesium
*************************************************************************************
2.2 mg/dL
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
ALT
*************************************************************************************
20 IU/L
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Alkaline Phosphate
*************************************************************************************
57 IU/L
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
AST
*************************************************************************************
26 IU/L
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Amylase
*************************************************************************************
17 IU/L
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Total Bilirubin
*************************************************************************************
0.4 mg/dL
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Triglyceride
*************************************************************************************
120 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
WBC
*************************************************************************************
18.2 K/uL
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
Hgb
*************************************************************************************
10.4 g/dL
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
Hematocrit
*************************************************************************************
31.5 %
*************************************************************************************
[**2113-2-1**] 03:30 AM
*************************************************************************************
Current diet order / nutrition support: Diet: Ground solids, thin
*************************************************************************************
liquids; Ensure Pudding and Carnation Instant Breakfast with meals;
*************************************************************************************
calorie counts [**2-1**], [**2-2**], [**2-3**]
*************************************************************************************
GI: soft, (+) bowel sounds; green liquid stool
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
Estimation of current intake: Inadequate
*************************************************************************************
Specifics:
*************************************************************************************
Patient s/p MVR / AVR [**1-27**]. Extubated [**1-30**]. Seen by SLP [**1-31**] who
*************************************************************************************
recommended above altered consistency diet with 1:1 supervision. [**Name8 (MD) **]
*************************************************************************************
RN, patient took Ensure pudding and some Carnation Instant Breakfast
*************************************************************************************
shake this AM with a lot of encouragement. Patient takes very small
*************************************************************************************
bites and is a picky eater. RN reports wife to bring in a list of
*************************************************************************************
foods that patient likes. Calorie counts starting today. Concerned
*************************************************************************************
with nutrition status given poor po
*************************************************************************************
s during admit (refusing po
*************************************************************************************
s at
*************************************************************************************
times), only received tube feed briefly on/off and recent surgery.
*************************************************************************************
Would strongly recommend supplemental tube feed to optimize nutrition
*************************************************************************************
for post-op recovery.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
Current diet / nutrition support is appropriate:
*************************************************************************************
Encourage/assist with po
*************************************************************************************
o Encourage wife to bring in food preference list or food
*************************************************************************************
o Calorie counts
*************************************************************************************
please record on kitchen receipt percent
*************************************************************************************
eaten
*************************************************************************************
Oral supplements: Continue as ordered
*************************************************************************************
Multivitamin / Mineral supplement: continue current
*************************************************************************************
Tube feeding recommendations:
*************************************************************************************
o Consider placing NGT and beginning tube feeds to supplement
*************************************************************************************
poor po
*************************************************************************************
o Tube feed goal would be: Nutren Pulmonary @ 45ml/hr = 1620
*************************************************************************************
calories and 73g protein
*************************************************************************************
Check chemistry 10 panel daily
*************************************************************************************
Will follow, page if questions *[**Numeric Identifier 606**]
*************************************************************************************
"
*************************************************************************************
40461,Nutrition,"Subjective
*************************************************************************************
just extubated
*************************************************************************************
Objective
*************************************************************************************
Height
*************************************************************************************
Admit weight
*************************************************************************************
Daily weight
*************************************************************************************
Weight change
*************************************************************************************
BMI
*************************************************************************************
178 cm
*************************************************************************************
63 kg
*************************************************************************************
76.2 kg ([**2113-1-30**] 04:00 AM)
*************************************************************************************
19.9
*************************************************************************************
Pertinent medications: Multivitamins, others noted
*************************************************************************************
Labs:
*************************************************************************************
Value
*************************************************************************************
Date
*************************************************************************************
Glucose
*************************************************************************************
106 mg/dL
*************************************************************************************
[**2113-1-30**] 07:59 AM
*************************************************************************************
Glucose Finger Stick
*************************************************************************************
93
*************************************************************************************
[**2113-1-29**] 06:00 PM
*************************************************************************************
BUN
*************************************************************************************
20 mg/dL
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Creatinine
*************************************************************************************
1.6 mg/dL
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Sodium
*************************************************************************************
137 mEq/L
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Potassium
*************************************************************************************
3.5 mEq/L
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Chloride
*************************************************************************************
104 mEq/L
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
TCO2
*************************************************************************************
22 mEq/L
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
PO2 (arterial)
*************************************************************************************
85.[**Numeric Identifier 299**] mm Hg
*************************************************************************************
[**2113-1-30**] 09:19 AM
*************************************************************************************
PO2 (venous)
*************************************************************************************
48 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
PCO2 (arterial)
*************************************************************************************
33 mm Hg
*************************************************************************************
[**2113-1-30**] 09:19 AM
*************************************************************************************
PCO2 (venous)
*************************************************************************************
33 mm Hg
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (arterial)
*************************************************************************************
7.41 units
*************************************************************************************
[**2113-1-30**] 09:19 AM
*************************************************************************************
pH (venous)
*************************************************************************************
7.43 units
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
pH (urine)
*************************************************************************************
5.0 units
*************************************************************************************
[**2113-1-25**] 02:26 PM
*************************************************************************************
CO2 (Calc) arterial
*************************************************************************************
22 mEq/L
*************************************************************************************
[**2113-1-30**] 09:19 AM
*************************************************************************************
CO2 (Calc) venous
*************************************************************************************
23 mEq/L
*************************************************************************************
[**2113-1-21**] 05:21 PM
*************************************************************************************
Albumin
*************************************************************************************
2.2 g/dL
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Calcium non-ionized
*************************************************************************************
8.4 mg/dL
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Phosphorus
*************************************************************************************
5.2 mg/dL
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Ionized Calcium
*************************************************************************************
1.09 mmol/L
*************************************************************************************
[**2113-1-30**] 07:59 AM
*************************************************************************************
Magnesium
*************************************************************************************
2.1 mg/dL
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
ALT
*************************************************************************************
20 IU/L
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Alkaline Phosphate
*************************************************************************************
57 IU/L
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
AST
*************************************************************************************
26 IU/L
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Amylase
*************************************************************************************
17 IU/L
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Total Bilirubin
*************************************************************************************
0.4 mg/dL
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Triglyceride
*************************************************************************************
120 mg/dL
*************************************************************************************
[**2113-1-25**] 03:36 AM
*************************************************************************************
WBC
*************************************************************************************
11.5 K/uL
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Hgb
*************************************************************************************
10.3 g/dL
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Hematocrit
*************************************************************************************
30.1 %
*************************************************************************************
[**2113-1-30**] 03:25 AM
*************************************************************************************
Current diet order / nutrition support: Nutren Pulmonary Full strength;
*************************************************************************************
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 50 ml/hr
*************************************************************************************
Residual Check: q4h Hold feeding for residual >= : 200 ml
*************************************************************************************
Flush w/ 30 ml water q4h ( not running)
*************************************************************************************
GI: soft, flesiseal in place
*************************************************************************************
SKIN: stage 2 wounds
*************************************************************************************
Assessment of Nutritional Status
*************************************************************************************
49 year old male admitted on [**1-15**] with endocarditis s/p MVR and aortic
*************************************************************************************
valve debridement on [**1-27**], patient extubated this morning. Patient
*************************************************************************************
well known to me from CCU, patient with minimal nutrition since
*************************************************************************************
hospital admission (previously refused po food and nutrition
*************************************************************************************
supplements in the ccu, received 1 day of tube feed prior to OR.
*************************************************************************************
Patient at very high risk for malnutrition, highly recommend replace
*************************************************************************************
feeding tube, restart tube feed as temporary nutrition support for post
*************************************************************************************
op recovery.
*************************************************************************************
Medical Nutrition Therapy Plan - Recommend the Following
*************************************************************************************
Adv diet if remains medically stable
*************************************************************************************
Continue tube feed as supplemental nutrition support: goal
*************************************************************************************
Nutren Pulmonary goal 45ml/hr to provide 1620kcal/73.4g protein
*************************************************************************************
Phos binder if serum phos remains elevated
*************************************************************************************
Check chemistry 10 panel daily, replete prn
*************************************************************************************
BS management
*************************************************************************************
Other: [**Numeric Identifier 943**]
*************************************************************************************
"
*************************************************************************************
In [42]:
import en_core_sci_md
nlp = en_core_sci_md.load()
In [43]:
doc = []
for i in range(len(notes)):
doc.append(nlp(notes[i]))
for ent in doc[-1].ents:
print(ent.text, ent.start_char, ent.end_char, ent.label_)
print("****************************************************************************************************")
SUBJECT_ID 0 10 ENTITY CATEGORY 11 19 ENTITY **************************************************************************************************** MICU 40 44 ENTITY aspiration 61 71 ENTITY Diet 74 78 ENTITY **************************************************************************************************** NPO 6 9 ENTITY NGT 11 14 ENTITY medication 22 32 ENTITY Noted 35 40 ENTITY transition 49 59 ENTITY comfort 63 70 ENTITY **************************************************************************************************** focused care 3 15 ENTITY **************************************************************************************************** Will sign 3 12 ENTITY time 25 29 ENTITY consult 39 46 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** medications 13 24 ENTITY RISS 26 30 ENTITY SS 32 34 ENTITY lytes 35 40 ENTITY thiamin 42 49 ENTITY folate 51 57 ENTITY lasix 59 64 ENTITY bowel 66 71 ENTITY **************************************************************************************************** regimen 3 10 ENTITY MOM 12 15 ENTITY reglan 17 23 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Ionized Calcium 3 18 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Fibersource 43 54 ENTITY HN@60mL/hr 55 65 ENTITY **************************************************************************************************** infusing 23 31 ENTITY **************************************************************************************************** GI 3 5 ENTITY soft/+bs 11 19 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** Specifics 3 12 ENTITY **************************************************************************************************** Pt 3 5 ENTITY extubated 6 15 ENTITY Pt 32 34 ENTITY TF 61 63 ENTITY **************************************************************************************************** goal 4 8 ENTITY **************************************************************************************************** nutrition 26 35 ENTITY Anticipate diet advancement 44 71 ENTITY **************************************************************************************************** **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** Advance diet 3 15 ENTITY team 20 24 ENTITY swallow 28 35 ENTITY eval 36 40 ENTITY s/s 53 56 ENTITY aspiration 60 70 ENTITY **************************************************************************************************** advance diet 3 15 ENTITY SLP- 20 24 ENTITY NGT 34 37 ENTITY resume TF's 42 53 ENTITY **************************************************************************************************** **************************************************************************************************** plan 15 19 ENTITY page 28 32 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** intubated 3 12 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Ideal body weight 3 20 ENTITY **************************************************************************************************** Ideal body weight 5 22 ENTITY **************************************************************************************************** Adjusted 3 11 ENTITY **************************************************************************************************** Usual body weight 3 20 ENTITY **************************************************************************************************** Usual body weight 5 22 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Diagnosis 3 12 ENTITY S/P Fall 14 22 ENTITY **************************************************************************************************** PMH 3 6 ENTITY etoh 9 13 ENTITY smoker 15 21 ENTITY cirrhosis 23 32 ENTITY **************************************************************************************************** Food allergies 3 17 ENTITY intolerances 22 34 ENTITY NKFA 37 41 ENTITY **************************************************************************************************** medications 13 24 ENTITY fentanyl 26 34 ENTITY LR 36 38 ENTITY lasix 51 56 ENTITY RISS 66 70 ENTITY IV 72 74 ENTITY **************************************************************************************************** **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Ionized Calcium 3 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** ALT 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** Alkaline Phosphate 3 21 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** AST 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** Total 3 8 ENTITY Bilirubin 9 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY NPO 43 46 ENTITY replete 47 54 ENTITY fiber 60 65 ENTITY **************************************************************************************************** **************************************************************************************************** GI 3 5 ENTITY OGT 7 10 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** risk 6 10 ENTITY malnutrition 15 27 ENTITY **************************************************************************************************** Pt 3 5 ENTITY risk 9 13 ENTITY NPO 22 25 ENTITY hypocaloric diet 28 44 ENTITY **************************************************************************************************** Estimated Nutritional Needs 3 30 ENTITY **************************************************************************************************** Calories 3 11 ENTITY **************************************************************************************************** Protein 3 10 ENTITY **************************************************************************************************** Fluid 3 8 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY intake 26 32 ENTITY Adequate 41 49 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY current 17 24 ENTITY intake 25 31 ENTITY Inadequate 33 43 ENTITY **************************************************************************************************** Specifics 3 12 ENTITY year 17 21 ENTITY male 26 30 ENTITY OSH 48 51 ENTITY intubated 53 62 ENTITY Pt 70 72 ENTITY **************************************************************************************************** S/P 3 6 ENTITY CT 13 15 ENTITY Stage IV splenic laceration 22 49 ENTITY TF 62 64 ENTITY **************************************************************************************************** minimal residuals 3 20 ENTITY Name8 24 29 ENTITY RN 39 41 ENTITY TF 51 53 ENTITY kcals/89 g Pro 68 82 ENTITY **************************************************************************************************** Recommend 3 12 ENTITY changing TF 13 24 ENTITY nutritional 40 51 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** Check chemistry 12 27 ENTITY daily 37 42 ENTITY **************************************************************************************************** Change 12 18 ENTITY TF 19 21 ENTITY goal 25 29 ENTITY Fibersource 33 44 ENTITY HN 45 47 ENTITY **************************************************************************************************** Pro 3 6 ENTITY **************************************************************************************************** Pls page 12 20 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** intubated 3 12 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Ideal body weight 3 20 ENTITY **************************************************************************************************** Ideal body weight 5 22 ENTITY **************************************************************************************************** Adjusted 3 11 ENTITY **************************************************************************************************** Usual body weight 3 20 ENTITY **************************************************************************************************** Usual body weight 5 22 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Diagnosis 3 12 ENTITY S/P Fall 14 22 ENTITY **************************************************************************************************** PMH 3 6 ENTITY etoh 9 13 ENTITY smoker 15 21 ENTITY cirrhosis 23 32 ENTITY **************************************************************************************************** Food allergies 3 17 ENTITY intolerances 22 34 ENTITY NKFA 37 41 ENTITY **************************************************************************************************** medications 13 24 ENTITY fentanyl 26 34 ENTITY LR 36 38 ENTITY lasix 51 56 ENTITY RISS 66 70 ENTITY IV 72 74 ENTITY **************************************************************************************************** **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Ionized Calcium 3 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** ALT 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** Alkaline Phosphate 3 21 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** AST 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** Total 3 8 ENTITY Bilirubin 9 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY NPO 43 46 ENTITY replete 47 54 ENTITY fiber 60 65 ENTITY **************************************************************************************************** **************************************************************************************************** GI 3 5 ENTITY OGT 7 10 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** risk 6 10 ENTITY malnutrition 15 27 ENTITY **************************************************************************************************** Pt 3 5 ENTITY risk 9 13 ENTITY NPO 22 25 ENTITY hypocaloric diet 28 44 ENTITY **************************************************************************************************** Estimated Nutritional Needs 3 30 ENTITY **************************************************************************************************** Calories 3 11 ENTITY **************************************************************************************************** Protein 3 10 ENTITY **************************************************************************************************** Fluid 3 8 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY intake 26 32 ENTITY Adequate 41 49 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY current 17 24 ENTITY intake 25 31 ENTITY Inadequate 33 43 ENTITY **************************************************************************************************** Specifics 3 12 ENTITY year 17 21 ENTITY male 26 30 ENTITY OSH 48 51 ENTITY intubated 53 62 ENTITY Pt 70 72 ENTITY **************************************************************************************************** S/P 3 6 ENTITY CT 13 15 ENTITY Stage IV splenic laceration 22 49 ENTITY TF 62 64 ENTITY **************************************************************************************************** minimal residuals 3 20 ENTITY Name8 24 29 ENTITY RN 39 41 ENTITY TF 51 53 ENTITY kcals/89 g Pro 68 82 ENTITY **************************************************************************************************** Recommend 3 12 ENTITY changing TF 13 24 ENTITY nutritional 40 51 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** Check chemistry 12 27 ENTITY daily 37 42 ENTITY **************************************************************************************************** Change 12 18 ENTITY TF 19 21 ENTITY goal 25 29 ENTITY Fibersource 33 44 ENTITY HN 45 47 ENTITY **************************************************************************************************** Pro 3 6 ENTITY **************************************************************************************************** Pls page 12 20 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Ideal body weight 3 20 ENTITY **************************************************************************************************** Ideal body weight 5 22 ENTITY **************************************************************************************************** Adjusted 3 11 ENTITY **************************************************************************************************** Usual body weight 3 20 ENTITY **************************************************************************************************** Usual body weight 5 22 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Diagnosis 3 12 ENTITY Head Bleed 14 24 ENTITY **************************************************************************************************** PMH 3 6 ENTITY DM 9 11 ENTITY **************************************************************************************************** Food allergies 3 17 ENTITY intolerances 22 34 ENTITY **************************************************************************************************** Pertinent medications 3 24 ENTITY Esmolol 26 33 ENTITY famotidine 35 45 ENTITY colace 47 53 ENTITY lytes 55 60 ENTITY dilantin 65 73 ENTITY **************************************************************************************************** ssri 3 7 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Ionized Calcium 3 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Phenytoin 3 12 ENTITY Dilantin 14 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Replete 43 50 ENTITY fiber 56 61 ENTITY **************************************************************************************************** Goal rate 13 22 ENTITY **************************************************************************************************** Residual Check 3 17 ENTITY feeding 28 35 ENTITY residual 40 48 ENTITY **************************************************************************************************** GI 3 5 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** risk 6 10 ENTITY malnutrition 15 27 ENTITY **************************************************************************************************** Pt 3 5 ENTITY risk 9 13 ENTITY NPO 22 25 ENTITY hypocaloric diet 28 44 ENTITY **************************************************************************************************** Estimated Nutritional Needs 3 30 ENTITY **************************************************************************************************** Calories 3 11 ENTITY [**2027**]-2200 13 28 ENTITY BEE 30 33 ENTITY **************************************************************************************************** Protein 3 10 ENTITY **************************************************************************************************** Fluid 3 8 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY intake 26 32 ENTITY Adequate 34 42 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY current 17 24 ENTITY intake 25 31 ENTITY Inadequate 33 43 ENTITY **************************************************************************************************** Specifics 3 12 ENTITY **************************************************************************************************** male 9 13 ENTITY s/p 14 17 ENTITY head trauma 36 47 ENTITY right parietal-occipital 49 74 ENTITY **************************************************************************************************** SAH 3 6 ENTITY left intraparenchymal bleed 10 37 ENTITY contre-coup injury 40 58 ENTITY Pt 60 62 ENTITY **************************************************************************************************** tol 27 30 ENTITY goal TF 31 38 ENTITY issue 47 52 ENTITY per chart 54 63 ENTITY **************************************************************************************************** gag 3 6 ENTITY extubate 21 29 ENTITY extubate 53 61 ENTITY **************************************************************************************************** TF 13 15 ENTITY needs 36 41 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** Tube 3 7 ENTITY feeding 8 15 ENTITY recommendations 16 31 ENTITY **************************************************************************************************** Check chemistry 3 18 ENTITY daily 28 33 ENTITY replete 38 45 ENTITY **************************************************************************************************** Cont 3 7 ENTITY Bg 8 10 ENTITY management 11 21 ENTITY **************************************************************************************************** Pplease page 3 15 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Ideal body weight 3 20 ENTITY **************************************************************************************************** Ideal body weight 5 22 ENTITY **************************************************************************************************** Adjusted 3 11 ENTITY **************************************************************************************************** Usual body weight 3 20 ENTITY **************************************************************************************************** Usual body weight 5 22 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Diagnosis 3 12 ENTITY Head Bleed 14 24 ENTITY **************************************************************************************************** PMH 3 6 ENTITY DM 9 11 ENTITY HTN 13 16 ENTITY **************************************************************************************************** Food allergies 3 17 ENTITY intolerances 22 34 ENTITY **************************************************************************************************** Pertinent medications 3 24 ENTITY Esmolol 26 33 ENTITY famotidine 35 45 ENTITY colace 47 53 ENTITY lytes 55 60 ENTITY dilantin 65 73 ENTITY **************************************************************************************************** ssri 3 7 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Ionized Calcium 3 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Phenytoin 3 12 ENTITY Dilantin 14 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 26 28 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Replete 43 50 ENTITY fiber 56 61 ENTITY **************************************************************************************************** Goal rate 13 22 ENTITY **************************************************************************************************** Residual Check 3 17 ENTITY feeding 28 35 ENTITY residual 40 48 ENTITY **************************************************************************************************** GI 3 5 ENTITY Soft 7 11 ENTITY Non-distended 13 26 ENTITY Non-tender 28 38 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** risk 6 10 ENTITY malnutrition 15 27 ENTITY **************************************************************************************************** Pt 3 5 ENTITY risk 9 13 ENTITY NPO 22 25 ENTITY **************************************************************************************************** Estimated Nutritional Needs 3 30 ENTITY **************************************************************************************************** Calories 3 11 ENTITY BEE 24 27 ENTITY **************************************************************************************************** Protein 3 10 ENTITY **************************************************************************************************** Fluid 3 8 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY intake 26 32 ENTITY adequate 41 49 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY current 17 24 ENTITY intake 25 31 ENTITY Inadequate 33 43 ENTITY **************************************************************************************************** Specifics 3 12 ENTITY **************************************************************************************************** male 9 13 ENTITY s/p 14 17 ENTITY head trauma 36 47 ENTITY right parietal-occipital 49 74 ENTITY **************************************************************************************************** SAH 3 6 ENTITY left intraparenchymal bleed 10 37 ENTITY contre-coup injury 40 58 ENTITY Pt 60 62 ENTITY **************************************************************************************************** tol 27 30 ENTITY goal TF 31 38 ENTITY issue 47 52 ENTITY per chart 54 63 ENTITY **************************************************************************************************** gag 3 6 ENTITY cough 8 13 ENTITY LF 29 31 ENTITY Name3 51 56 ENTITY plan 66 70 ENTITY extubate 74 82 ENTITY **************************************************************************************************** extubate 3 11 ENTITY TF 33 35 ENTITY needs 56 61 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** Tube 3 7 ENTITY feeding 8 15 ENTITY recommendations 16 31 ENTITY increase 34 42 ENTITY TF 43 45 ENTITY Replete 49 56 ENTITY Fiber 62 67 ENTITY goal 68 72 ENTITY **************************************************************************************************** **************************************************************************************************** Check chemistry 3 18 ENTITY daily 28 33 ENTITY prn 46 49 ENTITY **************************************************************************************************** Cont 3 7 ENTITY Bg 8 10 ENTITY management 11 21 ENTITY **************************************************************************************************** Please page 3 14 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** medications 13 24 ENTITY pepcid 26 32 ENTITY Heparin 34 41 ENTITY docusate 43 51 ENTITY Abx 53 56 ENTITY RISS 58 62 ENTITY **************************************************************************************************** **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Replete 43 50 ENTITY **************************************************************************************************** **************************************************************************************************** GI 3 5 ENTITY soft/+bs 12 20 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY current 17 24 ENTITY intake 25 31 ENTITY Inadequate 33 43 ENTITY **************************************************************************************************** Specifics 3 12 ENTITY **************************************************************************************************** Pt s/p 3 9 ENTITY IVC 24 27 ENTITY **************************************************************************************************** infusing 12 20 ENTITY **************************************************************************************************** goal 20 24 ENTITY estimated kcal 42 56 ENTITY **************************************************************************************************** increase 36 44 ENTITY goal rate 45 54 ENTITY TF 58 60 ENTITY **************************************************************************************************** **************************************************************************************************** underfeeding 3 15 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** Multivitamin 3 15 ENTITY Mineral supplement 18 36 ENTITY vua TF 38 44 ENTITY **************************************************************************************************** Tube 3 7 ENTITY feeding 8 15 ENTITY recommendations 16 31 ENTITY Increase 33 41 ENTITY rate 50 54 ENTITY **************************************************************************************************** kcals/112 gr aa 3 18 ENTITY **************************************************************************************************** BG 3 5 ENTITY management 6 16 ENTITY **************************************************************************************************** page 10 14 ENTITY **************************************************************************************************** **************************************************************************************************** NPO 34 37 ENTITY **************************************************************************************************** days 3 7 ENTITY patient's 12 21 ENTITY diet 22 26 ENTITY advanced 45 53 ENTITY tolerated 58 67 ENTITY **************************************************************************************************** nutrition support 36 53 ENTITY **************************************************************************************************** Potential 3 12 ENTITY nutrition risk 17 31 ENTITY Patient 33 40 ENTITY monitored 47 56 ENTITY **************************************************************************************************** intervention 3 15 ENTITY **************************************************************************************************** Comments 3 11 ENTITY **************************************************************************************************** Pt s/p LRRT [**4 3 19 ENTITY c/b hypoxia 27 38 ENTITY increased 43 52 ENTITY O2 53 55 ENTITY requirements 56 68 ENTITY PACU 72 76 ENTITY **************************************************************************************************** clears 3 9 ENTITY Clinically improving 28 48 ENTITY **************************************************************************************************** floor 3 8 ENTITY **************************************************************************************************** advance diet 16 28 ENTITY patient 50 57 ENTITY **************************************************************************************************** nutrition support 3 20 ENTITY **************************************************************************************************** progress 17 25 ENTITY tolerance 30 39 ENTITY **************************************************************************************************** questions 18 27 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Screening 3 12 ENTITY Noted 46 51 ENTITY patient 52 59 ENTITY comfort 63 70 ENTITY **************************************************************************************************** measures 3 11 ENTITY time 58 62 ENTITY **************************************************************************************************** consult 15 22 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** patient 3 10 ENTITY patient 58 65 ENTITY **************************************************************************************************** difficulty 3 13 ENTITY swallowing 14 24 ENTITY damaged 33 40 ENTITY salivary glands 41 56 ENTITY XRT 62 65 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Ideal body weight 3 20 ENTITY **************************************************************************************************** Ideal body weight 5 22 ENTITY **************************************************************************************************** Adjusted 3 11 ENTITY **************************************************************************************************** Usual body weight 3 20 ENTITY **************************************************************************************************** Usual body weight 5 22 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Diagnosis 3 12 ENTITY facial fx 14 24 ENTITY **************************************************************************************************** PMH 3 6 ENTITY breast ca 9 18 ENTITY tongue ca 20 29 ENTITY ovarian ca 31 41 ENTITY polymyalgia 43 54 ENTITY NIDDM 56 61 ENTITY vertigo 63 70 ENTITY **************************************************************************************************** falls 6 11 ENTITY **************************************************************************************************** Food allergies 3 17 ENTITY intolerances 22 34 ENTITY **************************************************************************************************** medications 13 24 ENTITY RISS 26 30 ENTITY protonix 40 48 ENTITY KCl 50 53 ENTITY Dextrose 64 72 ENTITY **************************************************************************************************** normal saline 10 23 ENTITY KCl 29 32 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 7 12 ENTITY **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY NPO 43 46 ENTITY **************************************************************************************************** GI 3 5 ENTITY obese 7 12 ENTITY bowel sounds 16 28 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** Obese 3 8 ENTITY risk 13 17 ENTITY malnutrition 22 34 ENTITY **************************************************************************************************** Pt 3 5 ENTITY risk 9 13 ENTITY NPO 22 25 ENTITY hypocaloric diet 28 44 ENTITY trauma 46 52 ENTITY **************************************************************************************************** Estimated Nutritional Needs 3 30 ENTITY body 49 53 ENTITY **************************************************************************************************** Calories 3 11 ENTITY **************************************************************************************************** Protein 3 10 ENTITY **************************************************************************************************** Fluid 3 8 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY intake 26 32 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY current 17 24 ENTITY intake 25 31 ENTITY Inadequate 33 43 ENTITY NPO 48 51 ENTITY status 52 58 ENTITY **************************************************************************************************** Specifics 3 12 ENTITY year 17 21 ENTITY female 26 32 ENTITY admitted 33 41 ENTITY hospital S/P 55 67 ENTITY **************************************************************************************************** home 6 10 ENTITY multiple injuries 16 33 ENTITY Le Forte fx 44 55 ENTITY multiple 57 65 ENTITY sinus 66 71 ENTITY **************************************************************************************************** fx 3 5 ENTITY orbital fx 7 17 ENTITY facial 19 25 ENTITY tongue swelling 30 45 ENTITY Patient 47 54 ENTITY SLP 63 66 ENTITY [**6-4** 70 78 ENTITY **************************************************************************************************** patient 19 26 ENTITY NPO 34 37 ENTITY patient 42 49 ENTITY **************************************************************************************************** diet 2 6 ENTITY **************************************************************************************************** advanced 3 11 ENTITY initiating 21 31 ENTITY tube feedings 32 45 ENTITY **************************************************************************************************** nutritional decline 3 22 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** diet 6 10 ENTITY tube feedings 49 62 ENTITY **************************************************************************************************** Replete 3 10 ENTITY Fiber 16 21 ENTITY goal 44 48 ENTITY **************************************************************************************************** protein 14 21 ENTITY **************************************************************************************************** Check residuals 3 18 ENTITY **************************************************************************************************** Monitor lytes 3 16 ENTITY glucose 21 28 ENTITY initiation 34 44 ENTITY tube feeding 48 60 ENTITY **************************************************************************************************** non-dextrose IV fluids 13 35 ENTITY tube feedings 41 54 ENTITY **************************************************************************************************** Implement 3 12 ENTITY SLP 17 20 ENTITY **************************************************************************************************** questions 67 76 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** oriented 3 11 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** AM 33 35 ENTITY **************************************************************************************************** **************************************************************************************************** medications 13 24 ENTITY Ranitidine 26 36 ENTITY Multi-vitamin 38 51 ENTITY ABX 53 56 ENTITY Folic Acid 58 68 ENTITY **************************************************************************************************** Thiamine 3 11 ENTITY Coumadin 13 21 ENTITY Lasix 23 28 ENTITY Colace 30 36 ENTITY KCl 45 48 ENTITY repletion 56 65 ENTITY **************************************************************************************************** Magnesium sulfate 3 20 ENTITY repletion 25 34 ENTITY Heparin drip 37 49 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY venous 8 14 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY venous 9 15 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY venous 7 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY venous 14 20 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Ionized Calcium 3 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** ALT 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Alkaline Phosphate 3 21 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** AST 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Amylase 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Total 3 8 ENTITY Bilirubin 9 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Triglyceride 3 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 7 12 ENTITY **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Diet 43 47 ENTITY NPO 49 52 ENTITY **************************************************************************************************** Calorie counts 3 17 ENTITY **************************************************************************************************** GI 3 5 ENTITY soft 7 11 ENTITY bowel sounds 17 29 ENTITY stool 37 42 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY current 17 24 ENTITY intake 25 31 ENTITY Inadequate 33 43 ENTITY **************************************************************************************************** Specifics 3 12 ENTITY **************************************************************************************************** year 6 10 ENTITY male 15 19 ENTITY mitral valve endocarditis 25 50 ENTITY preop stroke 52 64 ENTITY MVR 69 72 ENTITY **************************************************************************************************** Name8 18 23 ENTITY NamePattern1 59 71 ENTITY NamePattern1 95 107 ENTITY debridement 118 129 ENTITY aortic valve [**1 133 150 ENTITY Patient 159 166 ENTITY **************************************************************************************************** prolonged 3 12 ENTITY poor 13 17 ENTITY **************************************************************************************************** ground solids 24 37 ENTITY thin liquid 40 51 ENTITY **************************************************************************************************** diet 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** calories 11 19 ENTITY video swallow 41 54 ENTITY evaluation 55 65 ENTITY AM 71 73 ENTITY **************************************************************************************************** SLP 3 6 ENTITY NPO 17 20 ENTITY PA 43 45 ENTITY **************************************************************************************************** PEG placement 10 23 ENTITY **************************************************************************************************** NGT 30 33 ENTITY patient 48 55 ENTITY **************************************************************************************************** PEG 14 17 ENTITY long term 22 31 ENTITY **************************************************************************************************** nutritional decline 3 22 ENTITY optimize 27 35 ENTITY nutrition 36 45 ENTITY post-op healing 50 65 ENTITY Noted 68 73 ENTITY **************************************************************************************************** multiple 3 11 ENTITY lyte 12 16 ENTITY repletions 17 27 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** diet 18 22 ENTITY nutrition support 25 42 ENTITY **************************************************************************************************** NPO 3 6 ENTITY SLP 11 14 ENTITY recommendations 15 30 ENTITY **************************************************************************************************** SLP 13 16 ENTITY follow up 17 26 ENTITY **************************************************************************************************** Tube 10 14 ENTITY feeding 15 22 ENTITY recommendations 23 38 ENTITY PEG 51 54 ENTITY **************************************************************************************************** feeding tube 18 30 ENTITY Isosource 55 64 ENTITY **************************************************************************************************** tolerated 23 32 ENTITY goal 36 40 ENTITY calories 59 67 ENTITY **************************************************************************************************** protein 7 14 ENTITY **************************************************************************************************** tube feed 32 41 ENTITY **************************************************************************************************** Multivitamin 10 22 ENTITY Mineral supplement 25 43 ENTITY **************************************************************************************************** Check chemistry 10 25 ENTITY daily 35 40 ENTITY **************************************************************************************************** Replete 13 20 ENTITY lytes 21 26 ENTITY PRN 27 30 ENTITY **************************************************************************************************** page 16 20 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Patient oob 3 14 ENTITY tube feed running 16 33 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** medications 13 24 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY venous 8 14 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY venous 9 15 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY venous 7 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY venous 14 20 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Ionized Calcium 3 18 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** ALT 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Alkaline Phosphate 3 21 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** AST 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Amylase 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Total 3 8 ENTITY Bilirubin 9 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Triglyceride 3 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Replete 43 50 ENTITY fiber 56 61 ENTITY **************************************************************************************************** strength 3 11 ENTITY **************************************************************************************************** rate 12 16 ENTITY Advance rate 28 40 ENTITY Goal rate 54 63 ENTITY **************************************************************************************************** Residual Check 3 17 ENTITY feeding 28 35 ENTITY residual 40 48 ENTITY **************************************************************************************************** Flush 3 8 ENTITY water 18 23 ENTITY **************************************************************************************************** GI 3 5 ENTITY Abdominal 7 16 ENTITY Soft 18 22 ENTITY Non-tender 39 49 ENTITY Bowel sounds 51 63 ENTITY **************************************************************************************************** PEG site 3 11 ENTITY clean 12 17 ENTITY dry 22 25 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** year 6 10 ENTITY male 15 19 ENTITY PEG placement yesterday 25 48 ENTITY tube feed 50 59 ENTITY **************************************************************************************************** yesterday 3 12 ENTITY tolerated 14 23 ENTITY Isosource 24 33 ENTITY tube feed ordered 44 61 ENTITY changed 62 69 ENTITY **************************************************************************************************** Replete 3 10 ENTITY fiber 16 21 ENTITY morning 27 34 ENTITY spoke 36 41 ENTITY patient 65 72 ENTITY **************************************************************************************************** special tube feed 6 23 ENTITY Fibersource 45 56 ENTITY HN 57 59 ENTITY **************************************************************************************************** formula 3 10 ENTITY excess 20 26 ENTITY amount 27 33 ENTITY protein 37 44 ENTITY Noted discharge 46 61 ENTITY **************************************************************************************************** progress 3 11 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** Tube 10 14 ENTITY feeding 15 22 ENTITY Fibersource 24 35 ENTITY HN 36 38 ENTITY goal 39 43 ENTITY **************************************************************************************************** **************************************************************************************************** Check chemistry 10 25 ENTITY daily 35 40 ENTITY **************************************************************************************************** BS 19 21 ENTITY management 22 32 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Patient asleep 3 17 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** AM 33 35 ENTITY **************************************************************************************************** **************************************************************************************************** medications 13 24 ENTITY Multiple 26 34 ENTITY Vitamins 35 43 ENTITY Furosemide 45 55 ENTITY Docusate Sodium 57 72 ENTITY **************************************************************************************************** **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY venous 8 14 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY venous 9 15 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY venous 7 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY venous 14 20 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Ionized Calcium 3 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** ALT 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Alkaline Phosphate 3 21 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** AST 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Amylase 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Total 3 8 ENTITY Bilirubin 9 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Triglyceride 3 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Non-Standard 43 55 ENTITY TPN 56 59 ENTITY Date 65 69 ENTITY **************************************************************************************************** **************************************************************************************************** Replete 3 10 ENTITY fiber 16 21 ENTITY **************************************************************************************************** rate 12 16 ENTITY Advance rate 28 40 ENTITY Goal rate 54 63 ENTITY **************************************************************************************************** Residual Check 3 17 ENTITY feeding 28 35 ENTITY residual 40 48 ENTITY **************************************************************************************************** Flush 3 8 ENTITY water 18 23 ENTITY **************************************************************************************************** GI 3 5 ENTITY Abdominal 7 16 ENTITY Soft 18 22 ENTITY Non-tender 39 49 ENTITY Bowel sounds 51 63 ENTITY **************************************************************************************************** PEG site 3 11 ENTITY clean 12 17 ENTITY dry 22 25 ENTITY gravity drainage 34 50 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** year 6 10 ENTITY male 15 19 ENTITY Mitral valve endocarditis 25 50 ENTITY preop stroke 52 64 ENTITY MVR 69 72 ENTITY **************************************************************************************************** debridement 7 18 ENTITY aortic valve [** 22 38 ENTITY patient 47 54 ENTITY evaluation 68 78 ENTITY **************************************************************************************************** TPN 3 6 ENTITY weekend 24 31 ENTITY PEG 47 50 ENTITY PEG 55 58 ENTITY **************************************************************************************************** yesterday 3 12 ENTITY plan 14 18 ENTITY tube feeds 28 38 ENTITY current 46 53 ENTITY tube feed 54 63 ENTITY **************************************************************************************************** meeting 3 10 ENTITY patient 11 18 ENTITY **************************************************************************************************** Noted 19 24 ENTITY patient 25 32 ENTITY post 38 42 ENTITY **************************************************************************************************** fluid restricted formula 19 43 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** TPN 34 37 ENTITY **************************************************************************************************** tube feed 3 12 ENTITY **************************************************************************************************** Tube feeding 10 22 ENTITY Isosource 1.5cal goal 24 45 ENTITY **************************************************************************************************** **************************************************************************************************** Start tube 10 20 ENTITY adv 41 44 ENTITY tol 55 58 ENTITY **************************************************************************************************** Check chemistry 10 25 ENTITY daily 35 40 ENTITY **************************************************************************************************** BS 19 21 ENTITY management 22 32 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** patient 3 10 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** AM 33 35 ENTITY **************************************************************************************************** **************************************************************************************************** medications 13 24 ENTITY D5 @10 ml/hr 26 38 ENTITY KCl 40 43 ENTITY repletion 52 61 ENTITY RISS 64 68 ENTITY IV 70 72 ENTITY **************************************************************************************************** lansoprazole 8 20 ENTITY famotidine 22 32 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY venous 8 14 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY venous 9 15 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY venous 7 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY venous 14 20 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** PM 24 26 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Ionized Calcium 3 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** ALT 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Alkaline Phosphate 3 21 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** AST 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Amylase 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Total 3 8 ENTITY Bilirubin 9 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Triglyceride 3 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY NPO 43 46 ENTITY **************************************************************************************************** GI 3 5 ENTITY soft 7 11 ENTITY hypoactive bowel sounds 13 36 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** Specifics 3 12 ENTITY Patient s/p video swallow 14 39 ENTITY patient 68 75 ENTITY **************************************************************************************************** NPO 3 6 ENTITY consult 17 24 ENTITY PPN 29 32 ENTITY recommendations 33 48 ENTITY PA 70 72 ENTITY **************************************************************************************************** plan 3 7 ENTITY PEG placement 15 28 ENTITY Monday 32 38 ENTITY supplement 46 56 ENTITY nutrition 57 66 ENTITY **************************************************************************************************** parenteral nutrition 3 23 ENTITY PEG 30 33 ENTITY Patient 54 61 ENTITY PICC 67 71 ENTITY **************************************************************************************************** Day 3 6 ENTITY TPN 9 12 ENTITY ordered 13 20 ENTITY NGT 39 42 ENTITY week 68 72 ENTITY **************************************************************************************************** team 32 36 ENTITY patient 44 51 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** Day 12 15 ENTITY TPN 18 21 ENTITY **************************************************************************************************** glycemic control 20 36 ENTITY goal 48 52 ENTITY TPN 53 56 ENTITY **************************************************************************************************** amino 17 22 ENTITY **************************************************************************************************** Check 12 17 ENTITY TG 18 20 ENTITY lipids 26 32 ENTITY **************************************************************************************************** PEG 17 20 ENTITY Isosource 39 48 ENTITY HN 49 51 ENTITY **************************************************************************************************** goal 3 7 ENTITY protein 39 46 ENTITY **************************************************************************************************** questions 64 73 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Patient asleep 3 17 ENTITY Name8 22 27 ENTITY MD 29 31 ENTITY RN 39 41 ENTITY patient 43 50 ENTITY po food 63 70 ENTITY supplements 74 85 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** AM 34 36 ENTITY **************************************************************************************************** fluid 13 18 ENTITY **************************************************************************************************** **************************************************************************************************** Ideal body weight 3 20 ENTITY **************************************************************************************************** Ideal body weight 5 22 ENTITY **************************************************************************************************** Adjusted 3 11 ENTITY **************************************************************************************************** Usual body weight 3 20 ENTITY **************************************************************************************************** Usual body weight 5 22 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Diagnosis 3 12 ENTITY MITRAL VALVE 14 26 ENTITY **************************************************************************************************** PMHx 3 7 ENTITY no 16 18 ENTITY years 37 42 ENTITY **************************************************************************************************** Food allergies 3 17 ENTITY intolerances 22 34 ENTITY **************************************************************************************************** medications 13 24 ENTITY Furosemide 26 36 ENTITY Milrinone 39 48 ENTITY Multivitamins 50 63 ENTITY Thiamine 65 73 ENTITY **************************************************************************************************** FoLIC Acid 3 13 ENTITY Nicotine 15 23 ENTITY Patch 24 29 ENTITY Heparin 31 38 ENTITY Docusate Sodium 40 55 ENTITY Nafcillin 58 67 ENTITY **************************************************************************************************** Potassium Chloride 3 21 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY venous 8 14 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY venous 9 15 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY venous 7 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY venous 14 20 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** ALT 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Alkaline Phosphate 3 21 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** AST 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Total 3 8 ENTITY Bilirubin 9 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Regular 43 50 ENTITY Supplement 52 62 ENTITY Ensure 64 70 ENTITY **************************************************************************************************** Plus breakfast 3 17 ENTITY lunch 19 24 ENTITY dinner 26 33 ENTITY **************************************************************************************************** GI 3 5 ENTITY Abdominal 7 16 ENTITY Soft 18 22 ENTITY Non-tender 24 34 ENTITY Bowel sounds 36 48 ENTITY **************************************************************************************************** Extremities 3 14 ENTITY Right lower extremity edema 16 43 ENTITY Absent 45 51 ENTITY Left lower extremity 53 73 ENTITY **************************************************************************************************** edema 3 8 ENTITY **************************************************************************************************** Skin 3 7 ENTITY Rash 16 20 ENTITY upper 22 27 ENTITY occ petechiae 43 56 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** risk 6 10 ENTITY malnutrition 15 27 ENTITY **************************************************************************************************** Patient 0 7 ENTITY risk 11 15 ENTITY Low 25 28 ENTITY intake 32 38 ENTITY illness 48 55 ENTITY multipl 73 80 ENTITY **************************************************************************************************** non-hemorrhagic 8 23 ENTITY **************************************************************************************************** infarcts 3 11 ENTITY suspicious 12 22 ENTITY septic emboli 27 40 ENTITY **************************************************************************************************** Estimated Nutritional Needs 3 30 ENTITY **************************************************************************************************** Calories 3 11 ENTITY BEE 24 27 ENTITY **************************************************************************************************** Protein 3 10 ENTITY **************************************************************************************************** Fluid 3 8 ENTITY **************************************************************************************************** Calculations 3 15 ENTITY Admit weight 26 38 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY intake 26 32 ENTITY Inadequate 34 44 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY current 17 24 ENTITY intake 25 31 ENTITY Inadequate 33 43 ENTITY **************************************************************************************************** Specifics 3 12 ENTITY **************************************************************************************************** year 6 10 ENTITY male 15 19 ENTITY staphylococcus aureus 34 55 ENTITY bacterial 56 65 ENTITY **************************************************************************************************** endocarditis 3 15 ENTITY severe 21 27 ENTITY mitral regurgitation [**3 28 53 ENTITY **************************************************************************************************** vegetations 3 14 ENTITY flail leaflet 19 32 ENTITY Patient transferred 35 54 ENTITY CT surgery 98 108 ENTITY evaluation 109 119 ENTITY management 133 143 ENTITY **************************************************************************************************** Patient 3 10 ENTITY swallow 26 33 ENTITY evaluation 34 44 ENTITY regular diet 59 71 ENTITY **************************************************************************************************** patient 7 14 ENTITY spoke 36 41 ENTITY morning 55 62 ENTITY **************************************************************************************************** NGT 15 18 ENTITY placement 19 28 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** Po 10 12 ENTITY tolerance 16 25 ENTITY **************************************************************************************************** Tube 10 14 ENTITY feeding 15 22 ENTITY recommendations 23 38 ENTITY Nutren Pulmonary goal 40 61 ENTITY **************************************************************************************************** **************************************************************************************************** Monitor tube feed tolerance 10 37 ENTITY **************************************************************************************************** Check chemistry 10 25 ENTITY daily 35 40 ENTITY replete 42 49 ENTITY **************************************************************************************************** phos binder 26 37 ENTITY serum phos 41 51 ENTITY elevated 60 68 ENTITY **************************************************************************************************** Start regular 10 23 ENTITY serum glucose 49 62 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Patient asleep 3 17 ENTITY Name8 22 27 ENTITY MD 29 31 ENTITY RN 39 41 ENTITY patient 43 50 ENTITY po food 63 70 ENTITY supplements 74 85 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** AM 34 36 ENTITY **************************************************************************************************** fluid 13 18 ENTITY **************************************************************************************************** **************************************************************************************************** Ideal body weight 3 20 ENTITY **************************************************************************************************** Ideal body weight 5 22 ENTITY **************************************************************************************************** Adjusted 3 11 ENTITY **************************************************************************************************** Usual body weight 3 20 ENTITY **************************************************************************************************** Usual body weight 5 22 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Diagnosis 3 12 ENTITY MITRAL VALVE 14 26 ENTITY **************************************************************************************************** PMHx 3 7 ENTITY no 16 18 ENTITY years 37 42 ENTITY **************************************************************************************************** Food allergies 3 17 ENTITY intolerances 22 34 ENTITY **************************************************************************************************** medications 13 24 ENTITY Furosemide 26 36 ENTITY Milrinone 39 48 ENTITY Multivitamins 50 63 ENTITY Thiamine 65 73 ENTITY **************************************************************************************************** FoLIC Acid 3 13 ENTITY Nicotine 15 23 ENTITY Patch 24 29 ENTITY Heparin 31 38 ENTITY Docusate Sodium 40 55 ENTITY Nafcillin 58 67 ENTITY **************************************************************************************************** Potassium Chloride 3 21 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY venous 8 14 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY venous 9 15 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY venous 7 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY venous 14 20 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** ALT 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Alkaline Phosphate 3 21 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** AST 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Total 3 8 ENTITY Bilirubin 9 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Regular 43 50 ENTITY Supplement 52 62 ENTITY Ensure 64 70 ENTITY **************************************************************************************************** Plus breakfast 3 17 ENTITY lunch 19 24 ENTITY dinner 26 33 ENTITY **************************************************************************************************** GI 3 5 ENTITY Abdominal 7 16 ENTITY Soft 18 22 ENTITY Non-tender 24 34 ENTITY Bowel sounds 36 48 ENTITY **************************************************************************************************** Extremities 3 14 ENTITY Right lower extremity edema 16 43 ENTITY Absent 45 51 ENTITY Left lower extremity 53 73 ENTITY **************************************************************************************************** edema 3 8 ENTITY **************************************************************************************************** Skin 3 7 ENTITY Rash 16 20 ENTITY upper 22 27 ENTITY occ petechiae 43 56 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** risk 6 10 ENTITY malnutrition 15 27 ENTITY **************************************************************************************************** Patient 0 7 ENTITY risk 11 15 ENTITY Low 25 28 ENTITY intake 32 38 ENTITY illness 48 55 ENTITY multipl 73 80 ENTITY **************************************************************************************************** non-hemorrhagic 8 23 ENTITY **************************************************************************************************** infarcts 3 11 ENTITY suspicious 12 22 ENTITY septic emboli 27 40 ENTITY **************************************************************************************************** Estimated Nutritional Needs 3 30 ENTITY **************************************************************************************************** Calories 3 11 ENTITY BEE 24 27 ENTITY **************************************************************************************************** Protein 3 10 ENTITY **************************************************************************************************** Fluid 3 8 ENTITY **************************************************************************************************** Calculations 3 15 ENTITY Admit weight 26 38 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY intake 26 32 ENTITY Inadequate 34 44 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY current 17 24 ENTITY intake 25 31 ENTITY Inadequate 33 43 ENTITY **************************************************************************************************** Specifics 3 12 ENTITY **************************************************************************************************** year 6 10 ENTITY male 15 19 ENTITY staphylococcus aureus 34 55 ENTITY bacterial 56 65 ENTITY **************************************************************************************************** endocarditis 3 15 ENTITY severe 21 27 ENTITY mitral regurgitation [**3 28 53 ENTITY **************************************************************************************************** vegetations 3 14 ENTITY flail leaflet 19 32 ENTITY Patient transferred 35 54 ENTITY CT surgery 98 108 ENTITY evaluation 109 119 ENTITY management 133 143 ENTITY **************************************************************************************************** Patient 3 10 ENTITY swallow 26 33 ENTITY evaluation 34 44 ENTITY regular diet 59 71 ENTITY **************************************************************************************************** patient 7 14 ENTITY spoke 36 41 ENTITY morning 55 62 ENTITY **************************************************************************************************** NGT 15 18 ENTITY placement 19 28 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** Po 10 12 ENTITY tolerance 16 25 ENTITY **************************************************************************************************** Tube 10 14 ENTITY feeding 15 22 ENTITY recommendations 23 38 ENTITY Nutren Pulmonary goal 40 61 ENTITY **************************************************************************************************** **************************************************************************************************** Monitor tube feed tolerance 10 37 ENTITY **************************************************************************************************** Check chemistry 10 25 ENTITY daily 35 40 ENTITY replete 42 49 ENTITY **************************************************************************************************** phos binder 26 37 ENTITY serum phos 41 51 ENTITY elevated 60 68 ENTITY **************************************************************************************************** Start regular 10 23 ENTITY serum glucose 49 62 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Cardiology Teaching 3 22 ENTITY Physician 23 32 ENTITY Note 33 37 ENTITY **************************************************************************************************** day 11 14 ENTITY examined 22 30 ENTITY physically present 39 57 ENTITY **************************************************************************************************** resident 3 11 ENTITY fellow 14 20 ENTITY portions 33 41 ENTITY services 49 57 ENTITY **************************************************************************************************** plans 33 38 ENTITY **************************************************************************************************** remarks 29 36 ENTITY **************************************************************************************************** Medical Decision Making 3 26 ENTITY **************************************************************************************************** Patient 3 10 ENTITY improving 18 27 ENTITY aggressive 41 51 ENTITY diuresis 52 60 ENTITY **************************************************************************************************** initiation 3 13 ENTITY Milrinone 17 26 ENTITY dyspneic 39 47 ENTITY saturations 52 63 ENTITY **************************************************************************************************** Renal service 17 30 ENTITY ARF 37 40 ENTITY multifactorial 44 58 ENTITY sediment 63 71 ENTITY **************************************************************************************************** ATM 7 10 ENTITY Createnine 12 22 ENTITY stable 26 32 ENTITY speaking 53 61 ENTITY **************************************************************************************************** somnolent 3 12 ENTITY wife 17 21 ENTITY night 82 87 ENTITY **************************************************************************************************** WBC 3 6 ENTITY K 17 18 ENTITY K 26 27 ENTITY continuing 53 63 ENTITY Nafcillin 64 73 ENTITY **************************************************************************************************** bllod cultures 8 22 ENTITY fever 28 33 ENTITY spikes 34 40 ENTITY fevers 52 58 ENTITY **************************************************************************************************** image 22 27 ENTITY abdomen 32 39 ENTITY intermittent 59 71 ENTITY **************************************************************************************************** abdominal pain 3 17 ENTITY C-[**Doctor First Name 91** 19 46 ENTITY **************************************************************************************************** delay surgery 3 16 ENTITY **************************************************************************************************** Entered 37 44 ENTITY By:[**Name (NI) **] [**Last Name (NamePattern1) **] 45 96 ENTITY MD 98 100 ENTITY **************************************************************************************************** on:[**2113-1-20**] 3 21 ENTITY PM 28 30 ENTITY **************************************************************************************************** **************************************************************************************************** patient 49 56 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** AM 32 34 ENTITY **************************************************************************************************** **************************************************************************************************** medications 13 24 ENTITY Milrinone 26 35 ENTITY protonix 37 45 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY venous 8 14 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY venous 9 15 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY venous 7 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY venous 14 20 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** ALT 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Alkaline Phosphate 3 21 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** AST 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Total 3 8 ENTITY Bilirubin 9 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Diet 43 47 ENTITY Regular/ heart healthy 49 71 ENTITY **************************************************************************************************** TID 20 23 ENTITY **************************************************************************************************** GI 3 5 ENTITY abd soft 7 15 ENTITY bowel sounds 17 29 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** year 6 10 ENTITY male 15 19 ENTITY staphylococcus aureus 34 55 ENTITY bacterial 56 65 ENTITY **************************************************************************************************** endocarditis 3 15 ENTITY severe 21 27 ENTITY mitral regurgitation [**3 28 53 ENTITY **************************************************************************************************** vegetations 3 14 ENTITY flail leaflet 19 32 ENTITY Patient transferred 35 54 ENTITY CT surgery 101 111 ENTITY evaluation 112 122 ENTITY management 136 146 ENTITY **************************************************************************************************** Patient 3 10 ENTITY swallow 26 33 ENTITY evaluation 34 44 ENTITY regular diet 59 71 ENTITY **************************************************************************************************** patient 7 14 ENTITY **************************************************************************************************** mental status 9 22 ENTITY **************************************************************************************************** Team 4 8 ENTITY NGT 33 36 ENTITY tube feeds 50 60 ENTITY **************************************************************************************************** feeding 3 10 ENTITY recommendations 15 30 ENTITY **************************************************************************************************** amount 3 9 ENTITY **************************************************************************************************** patient 2 9 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** estimated 26 35 ENTITY recommend 43 52 ENTITY Nutren Pulmonary 53 70 ENTITY **************************************************************************************************** **************************************************************************************************** po 23 25 ENTITY intake 26 32 ENTITY mental status 37 50 ENTITY tube 62 67 ENTITY **************************************************************************************************** feeds 3 8 ENTITY **************************************************************************************************** g- 20 22 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** intub 3 8 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** medications 13 24 ENTITY Multivitamins 26 39 ENTITY FoLIC Acid 41 51 ENTITY Pantoprazole 54 66 ENTITY **************************************************************************************************** Potassium Chloride 3 21 ENTITY Norepinephrine drip 23 42 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY venous 8 14 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY venous 9 15 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY venous 7 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY venous 14 20 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** ALT 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Alkaline Phosphate 3 21 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** AST 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Amylase 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Total 3 8 ENTITY Bilirubin 9 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Triglyceride 3 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Nutren Pulmonary Full strength 43 73 ENTITY **************************************************************************************************** Banana flakes 14 27 ENTITY **************************************************************************************************** rate 12 16 ENTITY Advance rate 28 40 ENTITY Goal rate 54 63 ENTITY **************************************************************************************************** Residual Check 3 17 ENTITY feeding 28 35 ENTITY residual 40 48 ENTITY **************************************************************************************************** water 19 24 ENTITY q8h 25 28 ENTITY morning 59 66 ENTITY **************************************************************************************************** NPO 3 6 ENTITY Procedure Start 11 26 ENTITY 12:01AM Procedure 34 51 ENTITY CSURG 53 58 ENTITY **************************************************************************************************** **************************************************************************************************** resume diet 10 21 ENTITY procedure 28 37 ENTITY **************************************************************************************************** GI 3 5 ENTITY soft 12 16 ENTITY ND 18 20 ENTITY NT 22 24 ENTITY NBS 26 29 ENTITY **************************************************************************************************** Ext 3 6 ENTITY pulses 11 17 ENTITY edema 22 27 ENTITY extremtiies 37 48 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** year 7 11 ENTITY male 16 20 ENTITY staphlyococcus aureus 35 56 ENTITY bacterial 57 66 ENTITY **************************************************************************************************** endocarditis 3 15 ENTITY severe 21 27 ENTITY mitral regurgitation [**3 28 53 ENTITY **************************************************************************************************** vegetations 3 14 ENTITY flail leaflet 19 32 ENTITY patient 34 41 ENTITY AVR 66 69 ENTITY **************************************************************************************************** MVR 3 6 ENTITY debridement 12 23 ENTITY epidural abscess 31 47 ENTITY Patient 50 57 ENTITY **************************************************************************************************** nutrition 3 12 ENTITY admission 19 28 ENTITY tube feed 43 52 ENTITY **************************************************************************************************** high risk 3 12 ENTITY malnutrition 17 29 ENTITY post cardiac 57 69 ENTITY **************************************************************************************************** surgery 3 10 ENTITY restart tube feed 24 41 ENTITY patient 45 52 ENTITY **************************************************************************************************** food 3 7 ENTITY admission 13 22 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** Multivitamin 10 22 ENTITY Mineral supplement 25 43 ENTITY discontinue 45 56 ENTITY **************************************************************************************************** tube feed restarts 6 24 ENTITY **************************************************************************************************** Tube 10 14 ENTITY feeding 15 22 ENTITY recommendations 23 38 ENTITY restart tube feed 40 57 ENTITY **************************************************************************************************** Check chemistry 10 25 ENTITY daily 35 40 ENTITY replete 42 49 ENTITY **************************************************************************************************** Start regular 10 23 ENTITY serum glucose 49 62 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Wt 3 5 ENTITY **************************************************************************************************** IBW 3 6 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** Diabetes 8 16 ENTITY Dyslipidemia 17 29 ENTITY Hypertension 30 42 ENTITY **************************************************************************************************** worst 3 8 ENTITY left posterior cerebral artery 18 48 ENTITY infarct(neurologic 49 68 ENTITY **************************************************************************************************** deficits 3 11 ENTITY left sided facial droop 22 45 ENTITY right sided neglect 47 66 ENTITY right 68 74 ENTITY **************************************************************************************************** sided hemiparesis 3 20 ENTITY expressive aphasia 22 40 ENTITY **************************************************************************************************** MVR(29mm St. [** 3 19 ENTITY Mechanical Valve 48 64 ENTITY Debridement 71 82 ENTITY Aortic Valve 86 98 ENTITY **************************************************************************************************** Teeth extraction 3 19 ENTITY **************************************************************************************************** Diet Order 3 13 ENTITY **************************************************************************************************** year 7 11 ENTITY male 16 20 ENTITY rehab 28 33 ENTITY M. 38 42 ENTITY Patient 42 49 ENTITY **************************************************************************************************** hospital CT 3 14 ENTITY depressed 22 31 ENTITY right frontal sinus 38 57 ENTITY Patient 59 66 ENTITY **************************************************************************************************** transferred 3 14 ENTITY **************************************************************************************************** Potential 3 12 ENTITY nutrition risk 17 31 ENTITY Patient 33 40 ENTITY monitored 47 56 ENTITY **************************************************************************************************** intervention 3 15 ENTITY **************************************************************************************************** Comments 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** Wt 3 5 ENTITY **************************************************************************************************** IBW 3 6 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** Diabetes 8 16 ENTITY Dyslipidemia 17 29 ENTITY Hypertension 30 42 ENTITY **************************************************************************************************** worst 3 8 ENTITY left posterior cerebral artery 18 48 ENTITY infarct(neurologic 49 68 ENTITY **************************************************************************************************** deficits 3 11 ENTITY left sided facial droop 22 45 ENTITY right sided neglect 47 66 ENTITY right 68 74 ENTITY **************************************************************************************************** sided hemiparesis 3 20 ENTITY expressive aphasia 22 40 ENTITY **************************************************************************************************** MVR(29mm St. [** 3 19 ENTITY Mechanical Valve 48 64 ENTITY Debridement 71 82 ENTITY Aortic Valve 86 98 ENTITY **************************************************************************************************** Teeth extraction 3 19 ENTITY **************************************************************************************************** Diet Order 3 13 ENTITY **************************************************************************************************** year 6 10 ENTITY male 15 19 ENTITY coumadin 24 32 ENTITY prosthetic mitral valve 39 62 ENTITY **************************************************************************************************** Staphylococcal endocarditis 10 37 ENTITY MV 41 43 ENTITY AV 48 50 ENTITY c/b multiple 52 64 ENTITY embolic 65 72 ENTITY **************************************************************************************************** strokes 3 10 ENTITY rehab s/p fall 25 39 ENTITY Patient 41 48 ENTITY diet 60 64 ENTITY **************************************************************************************************** vomiting 6 14 ENTITY Patient reports 16 31 ENTITY po 44 46 ENTITY intake 47 53 ENTITY **************************************************************************************************** Patient 22 29 ENTITY wt loss 40 47 ENTITY PTA 48 51 ENTITY usual body 66 76 ENTITY **************************************************************************************************** supplements 7 18 ENTITY increase 22 30 ENTITY caloric intake 31 45 ENTITY **************************************************************************************************** Recommendations 3 18 ENTITY **************************************************************************************************** Encourage pos 12 25 ENTITY supplements 30 41 ENTITY **************************************************************************************************** TID 28 31 ENTITY **************************************************************************************************** questions 64 73 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** oriented 3 11 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** AM 31 33 ENTITY **************************************************************************************************** **************************************************************************************************** medications 13 24 ENTITY Ranitidine 26 36 ENTITY ABX 38 41 ENTITY Folic Acid 43 53 ENTITY Thiamine 55 63 ENTITY **************************************************************************************************** Multi-vitamin 3 16 ENTITY lasix 18 23 ENTITY Colace (Held) 25 38 ENTITY KCl 40 43 ENTITY repletion 51 60 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY venous 8 14 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY venous 9 15 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY venous 7 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY venous 14 20 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Ionized Calcium 3 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** ALT 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Alkaline Phosphate 3 21 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** AST 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Amylase 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Total 3 8 ENTITY Bilirubin 9 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Triglyceride 3 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 24 26 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Diet 43 47 ENTITY Ground solids 49 62 ENTITY **************************************************************************************************** liquids 3 10 ENTITY Ensure Pudding 12 26 ENTITY Carnation Instant 31 48 ENTITY Breakfast 49 58 ENTITY meals 64 69 ENTITY **************************************************************************************************** calorie counts 3 17 ENTITY **************************************************************************************************** GI 3 5 ENTITY soft 7 11 ENTITY bowel sounds 17 29 ENTITY green liquid stool 31 49 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** Estimation 3 13 ENTITY current 17 24 ENTITY intake 25 31 ENTITY Inadequate 33 43 ENTITY **************************************************************************************************** Specifics 3 12 ENTITY **************************************************************************************************** Patient 3 10 ENTITY MVR 15 18 ENTITY AVR 21 24 ENTITY SLP 69 72 ENTITY **************************************************************************************************** recommended 3 14 ENTITY consistency diet 29 45 ENTITY supervision 55 66 ENTITY Name8 72 77 ENTITY **************************************************************************************************** RN 3 5 ENTITY patient 7 14 ENTITY Ensure pudding 20 34 ENTITY Carnation Instant 44 61 ENTITY **************************************************************************************************** shake 3 8 ENTITY AM 14 16 ENTITY encouragement 31 44 ENTITY Patient 47 54 ENTITY **************************************************************************************************** bites 3 8 ENTITY picky eater 18 29 ENTITY RN 32 34 ENTITY reports wife 35 47 ENTITY **************************************************************************************************** foods 3 8 ENTITY patient 14 21 ENTITY Calorie counts 30 44 ENTITY Concerned 62 71 ENTITY **************************************************************************************************** nutrition status 8 24 ENTITY poor 31 35 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** tube feed 25 34 ENTITY recent surgery 54 68 ENTITY **************************************************************************************************** supplemental tube 28 45 ENTITY nutrition 63 73 ENTITY **************************************************************************************************** post-op 7 14 ENTITY recovery 15 23 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** diet 18 22 ENTITY nutrition support 25 42 ENTITY **************************************************************************************************** Encourage/assist with 3 24 ENTITY **************************************************************************************************** Encourage wife 13 27 ENTITY food preference list 40 60 ENTITY food 64 69 ENTITY **************************************************************************************************** Calorie counts 13 27 ENTITY **************************************************************************************************** record 8 14 ENTITY kitchen 18 25 ENTITY receipt 26 33 ENTITY **************************************************************************************************** eaten 3 8 ENTITY **************************************************************************************************** Oral supplements 10 26 ENTITY **************************************************************************************************** Multivitamin 10 22 ENTITY Mineral supplement 25 43 ENTITY **************************************************************************************************** Tube 10 14 ENTITY feeding 15 22 ENTITY recommendations 23 38 ENTITY **************************************************************************************************** NGT 30 33 ENTITY beginning tube 38 52 ENTITY feeds 53 58 ENTITY **************************************************************************************************** poor 3 7 ENTITY **************************************************************************************************** feed goal 18 27 ENTITY Nutren Pulmonary @ 45ml/hr 38 64 ENTITY **************************************************************************************************** calories 3 11 ENTITY protein 20 27 ENTITY **************************************************************************************************** Check chemistry 10 25 ENTITY daily 35 40 ENTITY **************************************************************************************************** page 16 20 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** extubated 8 17 ENTITY **************************************************************************************************** Objective 3 12 ENTITY **************************************************************************************************** Height 3 9 ENTITY **************************************************************************************************** Admit weight 3 15 ENTITY **************************************************************************************************** Daily weight 3 15 ENTITY **************************************************************************************************** Weight change 3 16 ENTITY **************************************************************************************************** BMI 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** **************************************************************************************************** AM 34 36 ENTITY **************************************************************************************************** **************************************************************************************************** medications 13 24 ENTITY Multivitamins 26 39 ENTITY **************************************************************************************************** Labs 3 7 ENTITY **************************************************************************************************** Value 3 8 ENTITY **************************************************************************************************** **************************************************************************************************** Glucose 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Glucose Finger 3 17 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** BUN 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Creatinine 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Sodium 3 9 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Potassium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Chloride 3 11 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** TCO2 3 7 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY arterial 8 16 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PO2 3 6 ENTITY venous 8 14 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY arterial 9 17 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** PCO2 3 7 ENTITY venous 9 15 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY arterial 7 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY venous 7 13 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** pH 3 5 ENTITY urine 7 12 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** CO2 3 6 ENTITY Calc 8 12 ENTITY venous 14 20 ENTITY **************************************************************************************************** **************************************************************************************************** PM 25 27 ENTITY **************************************************************************************************** Albumin 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Calcium 3 10 ENTITY non-ionized 11 22 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Phosphorus 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Ionized Calcium 3 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Magnesium 3 12 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** ALT 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Alkaline Phosphate 3 21 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** AST 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Amylase 3 10 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Total 3 8 ENTITY Bilirubin 9 18 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Triglyceride 3 15 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** WBC 3 6 ENTITY **************************************************************************************************** K/uL 8 13 ENTITY **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hgb 3 6 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Hematocrit 3 13 ENTITY **************************************************************************************************** **************************************************************************************************** AM 25 27 ENTITY **************************************************************************************************** Current diet 3 15 ENTITY nutrition support 24 41 ENTITY Nutren Pulmonary Full strength 43 73 ENTITY **************************************************************************************************** rate 12 16 ENTITY Advance rate 28 40 ENTITY Goal rate 54 63 ENTITY **************************************************************************************************** Residual Check 3 17 ENTITY feeding 28 35 ENTITY residual 40 48 ENTITY **************************************************************************************************** Flush 3 8 ENTITY water q4h 18 27 ENTITY **************************************************************************************************** GI 3 5 ENTITY soft 7 11 ENTITY flesiseal 13 22 ENTITY **************************************************************************************************** SKIN 3 7 ENTITY stage 2 wounds 9 23 ENTITY **************************************************************************************************** Assessment 3 13 ENTITY Nutritional Status 17 35 ENTITY **************************************************************************************************** year 6 10 ENTITY male 15 19 ENTITY admitted 20 28 ENTITY [**1 32 36 ENTITY endocarditis 48 60 ENTITY MVR 65 68 ENTITY aortic 73 79 ENTITY **************************************************************************************************** valve debridement 3 20 ENTITY [**1 24 28 ENTITY patient 36 43 ENTITY extubated 44 53 ENTITY morning 59 66 ENTITY Patient 69 76 ENTITY **************************************************************************************************** CCU 25 28 ENTITY patient 30 37 ENTITY minimal 43 50 ENTITY nutrition 51 60 ENTITY **************************************************************************************************** hospital admission 3 21 ENTITY po food 42 49 ENTITY nutrition 54 64 ENTITY **************************************************************************************************** supplements 3 14 ENTITY ccu 22 25 ENTITY day 38 41 ENTITY tube feed 45 54 ENTITY OR 64 66 ENTITY **************************************************************************************************** Patient 3 10 ENTITY malnutrition 33 45 ENTITY **************************************************************************************************** feeding tube 3 15 ENTITY restart tube feed 17 34 ENTITY temporary 38 47 ENTITY nutrition support 48 65 ENTITY post 70 74 ENTITY **************************************************************************************************** recovery 6 14 ENTITY **************************************************************************************************** Medical Nutrition Therapy 3 28 ENTITY Plan 29 33 ENTITY Recommend 36 45 ENTITY **************************************************************************************************** Adv diet 10 18 ENTITY **************************************************************************************************** Continue tube feed 10 28 ENTITY supplemental nutrition support 32 62 ENTITY goal 64 68 ENTITY **************************************************************************************************** Nutren Pulmonary goal 3 24 ENTITY **************************************************************************************************** Phos binder 11 22 ENTITY serum phos 26 36 ENTITY elevated 45 53 ENTITY **************************************************************************************************** Check chemistry 10 25 ENTITY daily 35 40 ENTITY **************************************************************************************************** BS 10 12 ENTITY management 13 23 ENTITY **************************************************************************************************** **************************************************************************************************** ****************************************************************************************************
In [44]:
# Entity Visualizer
from spacy import displacy
for i in range(len(doc)):
displacy.render(doc[i], style="ent", jupyter=True)
print("************************************************************************************************************************************************")
SUBJECT_ID
ENTITY
,
CATEGORY
ENTITY
,TEXT
************************************************************************************************************************************************
17610,Nutrition,"Patient transferred to
MICU
ENTITY
for concern for
aspiration
ENTITY
.
Diet
ENTITY
changed
************************************************************************************************************************************************
to
NPO
ENTITY
;
NGT
ENTITY
in for
medication
ENTITY
.
Noted
ENTITY
plan to
transition
ENTITY
to
comfort
ENTITY
************************************************************************************************************************************************
focused care
ENTITY
.
************************************************************************************************************************************************
Will sign
ENTITY
off at this
time
ENTITY
. Please
consult
ENTITY
if needed. Pager *[**Numeric Identifier 5307**]
************************************************************************************************************************************************
"
************************************************************************************************************************************************
40493,Nutrition,"Objective
************************************************************************************************************************************************
Pertinent
medications
ENTITY
:
RISS
ENTITY
,
SS
ENTITY
lytes
ENTITY
,
thiamin
ENTITY
,
folate
ENTITY
,
lasix
ENTITY
,
bowel
ENTITY
************************************************************************************************************************************************
regimen
ENTITY
,
MOM
ENTITY
,
reglan
ENTITY
, others noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
93 mg/dL
************************************************************************************************************************************************
[**2172-11-9**] 01:50
AM
ENTITY
************************************************************************************************************************************************
Glucose Finger
ENTITY
Stick
************************************************************************************************************************************************
120
************************************************************************************************************************************************
[**2172-11-9**] 08:57
AM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
15 mg/dL
************************************************************************************************************************************************
[**2172-11-9**] 01:50
AM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
0.6 mg/dL
************************************************************************************************************************************************
[**2172-11-9**] 01:50
AM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
137 mEq/L
************************************************************************************************************************************************
[**2172-11-9**] 01:50
AM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
3.9 mEq/L
************************************************************************************************************************************************
[**2172-11-9**] 01:50
AM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
106 mEq/L
************************************************************************************************************************************************
[**2172-11-9**] 01:50
AM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
24 mEq/L
************************************************************************************************************************************************
[**2172-11-9**] 01:50
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
66 mm Hg
************************************************************************************************************************************************
[**2172-11-9**] 08:57
AM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
41 mm Hg
************************************************************************************************************************************************
[**2172-11-9**] 08:57
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
7.42 units
************************************************************************************************************************************************
[**2172-11-9**] 08:57
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
urine
ENTITY
)
************************************************************************************************************************************************
5.0 units
************************************************************************************************************************************************
[**2172-11-1**] 06:06
PM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
) arterial
************************************************************************************************************************************************
28 mEq/L
************************************************************************************************************************************************
[**2172-11-9**] 08:57
AM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
2.6 g/dL
************************************************************************************************************************************************
[**2172-11-3**] 02:24
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
8.7 mg/dL
************************************************************************************************************************************************
[**2172-11-9**] 01:50
AM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
4.5 mg/dL
************************************************************************************************************************************************
[**2172-11-9**] 01:50
AM
ENTITY
************************************************************************************************************************************************
Ionized Calcium
ENTITY
************************************************************************************************************************************************
1.11 mmol/L
************************************************************************************************************************************************
[**2172-11-5**] 01:34
PM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
2.2 mg/dL
************************************************************************************************************************************************
[**2172-11-9**] 01:50
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
Fibersource
ENTITY
HN@60mL/hr
ENTITY
(1728
************************************************************************************************************************************************
kcals/73 gr aa) not
infusing
ENTITY
************************************************************************************************************************************************
GI
ENTITY
: Abd
soft/+bs
ENTITY
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
Specifics
ENTITY
:
************************************************************************************************************************************************
Pt
ENTITY
extubated
ENTITY
earlier today.
Pt
ENTITY
was previously tolerating
TF
ENTITY
************************************************************************************************************************************************
s @
goal
ENTITY
,
************************************************************************************************************************************************
meeting 100% estimated
nutrition
ENTITY
needs.
Anticipate diet advancement
ENTITY
as
************************************************************************************************************************************************
able.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
Advance diet
ENTITY
per
team
ENTITY
c/
swallow
ENTITY
eval
ENTITY
if pt shows
s/s
ENTITY
of
aspiration
ENTITY
and
************************************************************************************************************************************************
advance diet
ENTITY
per
SLP-
ENTITY
vs place
NGT
ENTITY
and
resume TF's
ENTITY
if unable to take
************************************************************************************************************************************************
po
************************************************************************************************************************************************
Will follow
plan
ENTITY
-please
page
ENTITY
c/ ?'s #[**Numeric Identifier 1684**]
************************************************************************************************************************************************
"
************************************************************************************************************************************************
40493,Nutrition,"Subjective
************************************************************************************************************************************************
intubated
ENTITY
************************************************************************************************************************************************
Objective
ENTITY
************************************************************************************************************************************************
Height
ENTITY
************************************************************************************************************************************************
Admit weight
ENTITY
************************************************************************************************************************************************
Daily weight
ENTITY
************************************************************************************************************************************************
Weight change
ENTITY
************************************************************************************************************************************************
BMI
ENTITY
************************************************************************************************************************************************
168 cm
************************************************************************************************************************************************
65 kg
************************************************************************************************************************************************
23.1
************************************************************************************************************************************************
Ideal body weight
ENTITY
************************************************************************************************************************************************
%
Ideal body weight
ENTITY
************************************************************************************************************************************************
Adjusted
ENTITY
weight
************************************************************************************************************************************************
Usual body weight
ENTITY
************************************************************************************************************************************************
%
Usual body weight
ENTITY
************************************************************************************************************************************************
64.4 kg
************************************************************************************************************************************************
101%
************************************************************************************************************************************************
Diagnosis
ENTITY
:
S/P Fall
ENTITY
************************************************************************************************************************************************
PMH
ENTITY
:
etoh
ENTITY
,
smoker
ENTITY
,
cirrhosis
ENTITY
************************************************************************************************************************************************
Food allergies
ENTITY
and
intolerances
ENTITY
:
NKFA
ENTITY
************************************************************************************************************************************************
Pertinent
medications
ENTITY
:
fentanyl
ENTITY
,
LR
ENTITY
@ 10 ml/hr,
lasix
ENTITY
, versed,
RISS
ENTITY
,
IV
ENTITY
************************************************************************************************************************************************
abx, others noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
155 mg/dL
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Glucose Finger
ENTITY
Stick
************************************************************************************************************************************************
151
************************************************************************************************************************************************
[**2172-11-2**] 08:00
AM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
17 mg/dL
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
0.8 mg/dL
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
146 mEq/L
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
3.6 mEq/L
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
111 mEq/L
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
29 mEq/L
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
113 mm Hg
************************************************************************************************************************************************
[**2172-11-2**] 11:55
AM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
41 mm Hg
************************************************************************************************************************************************
[**2172-11-2**] 11:55
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
7.46 units
************************************************************************************************************************************************
[**2172-11-2**] 11:55
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
urine
ENTITY
)
************************************************************************************************************************************************
5.0 units
************************************************************************************************************************************************
[**2172-11-1**] 06:06
PM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
) arterial
************************************************************************************************************************************************
30 mEq/L
************************************************************************************************************************************************
[**2172-11-2**] 11:55
AM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
3.0 g/dL
************************************************************************************************************************************************
[**2172-10-31**] 02:55
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
8.1 mg/dL
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
2.5 mg/dL
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Ionized Calcium
ENTITY
************************************************************************************************************************************************
1.16 mmol/L
************************************************************************************************************************************************
[**2172-11-2**] 11:55
AM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
1.7 mg/dL
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
ALT
ENTITY
************************************************************************************************************************************************
14 IU/L
************************************************************************************************************************************************
[**2172-10-31**] 02:55
AM
ENTITY
************************************************************************************************************************************************
Alkaline Phosphate
ENTITY
************************************************************************************************************************************************
73 IU/L
************************************************************************************************************************************************
[**2172-10-31**] 02:55
AM
ENTITY
************************************************************************************************************************************************
AST
ENTITY
************************************************************************************************************************************************
43 IU/L
************************************************************************************************************************************************
[**2172-10-31**] 02:55
AM
ENTITY
************************************************************************************************************************************************
Total
ENTITY
Bilirubin
ENTITY
************************************************************************************************************************************************
3.4 mg/dL
************************************************************************************************************************************************
[**2172-10-31**] 02:55
AM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
23.2
K/uL
ENTITY
************************************************************************************************************************************************
[**2172-11-2**] 01:06
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
9.1 g/dL
************************************************************************************************************************************************
[**2172-11-2**] 01:06
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
27.2 %
************************************************************************************************************************************************
[**2172-11-2**] 01:06
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
NPO
ENTITY
replete
ENTITY
with
fiber
ENTITY
@ 60
************************************************************************************************************************************************
ml/hr
************************************************************************************************************************************************
GI
ENTITY
:
OGT
ENTITY
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
At
risk
ENTITY
for
malnutrition
ENTITY
************************************************************************************************************************************************
Pt
ENTITY
at
risk
ENTITY
due to:
NPO
ENTITY
/
hypocaloric diet
ENTITY
************************************************************************************************************************************************
Estimated Nutritional Needs
ENTITY
************************************************************************************************************************************************
Calories
ENTITY
: 1625-[**2114**] (25-30 cal/kg)
************************************************************************************************************************************************
Protein
ENTITY
: 78-91 (1.2-1.4 g/kg)
************************************************************************************************************************************************
Fluid
ENTITY
: per team
************************************************************************************************************************************************
Estimation
ENTITY
of previous
intake
ENTITY
: Likely
Adequate
ENTITY
************************************************************************************************************************************************
Estimation
ENTITY
of
current
ENTITY
intake
ENTITY
:
Inadequate
ENTITY
************************************************************************************************************************************************
Specifics
ENTITY
: 57
year
ENTITY
old
male
ENTITY
transferred from
OSH
ENTITY
,
intubated
ENTITY
there.
Pt
ENTITY
************************************************************************************************************************************************
S/P
ENTITY
fall
CT
ENTITY
shows
Stage IV splenic laceration
ENTITY
. Tolerating
TF
ENTITY
with
************************************************************************************************************************************************
minimal residuals
ENTITY
[**
Name8
ENTITY
(MD) **]
RN
ENTITY
. Current
TF
ENTITY
provides 1440
kcals/89 g Pro
ENTITY
.
************************************************************************************************************************************************
Recommend
ENTITY
changing TF
ENTITY
to better meet
nutritional
ENTITY
needs.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
1.
Check chemistry
ENTITY
10 panel
daily
ENTITY
************************************************************************************************************************************************
2.
Change
ENTITY
TF
ENTITY
to
goal
ENTITY
of
Fibersource
ENTITY
HN
ENTITY
@ 65ml/hr (1872 kcals/83 g
************************************************************************************************************************************************
Pro
ENTITY
)
************************************************************************************************************************************************
3.
Pls page
ENTITY
with questions [**Numeric Identifier 2584**]
************************************************************************************************************************************************
"
************************************************************************************************************************************************
40493,Nutrition,"Subjective
************************************************************************************************************************************************
intubated
ENTITY
************************************************************************************************************************************************
Objective
ENTITY
************************************************************************************************************************************************
Height
ENTITY
************************************************************************************************************************************************
Admit weight
ENTITY
************************************************************************************************************************************************
Daily weight
ENTITY
************************************************************************************************************************************************
Weight change
ENTITY
************************************************************************************************************************************************
BMI
ENTITY
************************************************************************************************************************************************
168 cm
************************************************************************************************************************************************
65 kg
************************************************************************************************************************************************
23.1
************************************************************************************************************************************************
Ideal body weight
ENTITY
************************************************************************************************************************************************
%
Ideal body weight
ENTITY
************************************************************************************************************************************************
Adjusted
ENTITY
weight
************************************************************************************************************************************************
Usual body weight
ENTITY
************************************************************************************************************************************************
%
Usual body weight
ENTITY
************************************************************************************************************************************************
64.4 kg
************************************************************************************************************************************************
101%
************************************************************************************************************************************************
Diagnosis
ENTITY
:
S/P Fall
ENTITY
************************************************************************************************************************************************
PMH
ENTITY
:
etoh
ENTITY
,
smoker
ENTITY
,
cirrhosis
ENTITY
************************************************************************************************************************************************
Food allergies
ENTITY
and
intolerances
ENTITY
:
NKFA
ENTITY
************************************************************************************************************************************************
Pertinent
medications
ENTITY
:
fentanyl
ENTITY
,
LR
ENTITY
@ 10 ml/hr,
lasix
ENTITY
, versed,
RISS
ENTITY
,
IV
ENTITY
************************************************************************************************************************************************
abx, others noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
155 mg/dL
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Glucose Finger
ENTITY
Stick
************************************************************************************************************************************************
151
************************************************************************************************************************************************
[**2172-11-2**] 08:00
AM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
17 mg/dL
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
0.8 mg/dL
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
146 mEq/L
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
3.6 mEq/L
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
111 mEq/L
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
29 mEq/L
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
113 mm Hg
************************************************************************************************************************************************
[**2172-11-2**] 11:55
AM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
41 mm Hg
************************************************************************************************************************************************
[**2172-11-2**] 11:55
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
7.46 units
************************************************************************************************************************************************
[**2172-11-2**] 11:55
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
urine
ENTITY
)
************************************************************************************************************************************************
5.0 units
************************************************************************************************************************************************
[**2172-11-1**] 06:06
PM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
) arterial
************************************************************************************************************************************************
30 mEq/L
************************************************************************************************************************************************
[**2172-11-2**] 11:55
AM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
3.0 g/dL
************************************************************************************************************************************************
[**2172-10-31**] 02:55
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
8.1 mg/dL
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
2.5 mg/dL
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
Ionized Calcium
ENTITY
************************************************************************************************************************************************
1.16 mmol/L
************************************************************************************************************************************************
[**2172-11-2**] 11:55
AM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
1.7 mg/dL
************************************************************************************************************************************************
[**2172-11-2**] 12:18
PM
ENTITY
************************************************************************************************************************************************
ALT
ENTITY
************************************************************************************************************************************************
14 IU/L
************************************************************************************************************************************************
[**2172-10-31**] 02:55
AM
ENTITY
************************************************************************************************************************************************
Alkaline Phosphate
ENTITY
************************************************************************************************************************************************
73 IU/L
************************************************************************************************************************************************
[**2172-10-31**] 02:55
AM
ENTITY
************************************************************************************************************************************************
AST
ENTITY
************************************************************************************************************************************************
43 IU/L
************************************************************************************************************************************************
[**2172-10-31**] 02:55
AM
ENTITY
************************************************************************************************************************************************
Total
ENTITY
Bilirubin
ENTITY
************************************************************************************************************************************************
3.4 mg/dL
************************************************************************************************************************************************
[**2172-10-31**] 02:55
AM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
23.2
K/uL
ENTITY
************************************************************************************************************************************************
[**2172-11-2**] 01:06
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
9.1 g/dL
************************************************************************************************************************************************
[**2172-11-2**] 01:06
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
27.2 %
************************************************************************************************************************************************
[**2172-11-2**] 01:06
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
NPO
ENTITY
replete
ENTITY
with
fiber
ENTITY
@ 60
************************************************************************************************************************************************
ml/hr
************************************************************************************************************************************************
GI
ENTITY
:
OGT
ENTITY
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
At
risk
ENTITY
for
malnutrition
ENTITY
************************************************************************************************************************************************
Pt
ENTITY
at
risk
ENTITY
due to:
NPO
ENTITY
/
hypocaloric diet
ENTITY
************************************************************************************************************************************************
Estimated Nutritional Needs
ENTITY
************************************************************************************************************************************************
Calories
ENTITY
: 1625-[**2114**] (25-30 cal/kg)
************************************************************************************************************************************************
Protein
ENTITY
: 78-91 (1.2-1.4 g/kg)
************************************************************************************************************************************************
Fluid
ENTITY
: per team
************************************************************************************************************************************************
Estimation
ENTITY
of previous
intake
ENTITY
: Likely
Adequate
ENTITY
************************************************************************************************************************************************
Estimation
ENTITY
of
current
ENTITY
intake
ENTITY
:
Inadequate
ENTITY
************************************************************************************************************************************************
Specifics
ENTITY
: 57
year
ENTITY
old
male
ENTITY
transferred from
OSH
ENTITY
,
intubated
ENTITY
there.
Pt
ENTITY
************************************************************************************************************************************************
S/P
ENTITY
fall
CT
ENTITY
shows
Stage IV splenic laceration
ENTITY
. Tolerating
TF
ENTITY
with
************************************************************************************************************************************************
minimal residuals
ENTITY
[**
Name8
ENTITY
(MD) **]
RN
ENTITY
. Current
TF
ENTITY
provides 1440
kcals/89 g Pro
ENTITY
.
************************************************************************************************************************************************
Recommend
ENTITY
changing TF
ENTITY
to better meet
nutritional
ENTITY
needs.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
1.
Check chemistry
ENTITY
10 panel
daily
ENTITY
************************************************************************************************************************************************
2.
Change
ENTITY
TF
ENTITY
to
goal
ENTITY
of
Fibersource
ENTITY
HN
ENTITY
@ 65ml/hr (1872 kcals/83 g
************************************************************************************************************************************************
Pro
ENTITY
)
************************************************************************************************************************************************
3.
Pls page
ENTITY
with questions [**Numeric Identifier 2584**]
************************************************************************************************************************************************
"
************************************************************************************************************************************************
61565,Nutrition,"Objective
************************************************************************************************************************************************
Height
ENTITY
************************************************************************************************************************************************
Admit weight
ENTITY
************************************************************************************************************************************************
Daily weight
ENTITY
************************************************************************************************************************************************
Weight change
ENTITY
************************************************************************************************************************************************
BMI
ENTITY
************************************************************************************************************************************************
178 cm
************************************************************************************************************************************************
88.2 kg
************************************************************************************************************************************************
27.8
************************************************************************************************************************************************
Ideal body weight
ENTITY
************************************************************************************************************************************************
%
Ideal body weight
ENTITY
************************************************************************************************************************************************
Adjusted
ENTITY
weight
************************************************************************************************************************************************
Usual body weight
ENTITY
************************************************************************************************************************************************
%
Usual body weight
ENTITY
************************************************************************************************************************************************
75.3 kg
************************************************************************************************************************************************
117%
************************************************************************************************************************************************
Diagnosis
ENTITY
:
Head Bleed
ENTITY
************************************************************************************************************************************************
PMH
ENTITY
:
DM
ENTITY
.
************************************************************************************************************************************************
Food allergies
ENTITY
and
intolerances
ENTITY
:
************************************************************************************************************************************************
Pertinent medications
ENTITY
:
Esmolol
ENTITY
,
famotidine
ENTITY
,
colace
ENTITY
,
lytes
ENTITY
ss,
dilantin
ENTITY
,
************************************************************************************************************************************************
ssri
ENTITY
, others noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
143 mg/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Glucose Finger
ENTITY
Stick
************************************************************************************************************************************************
155
************************************************************************************************************************************************
[**2100-11-1**] 02:00
AM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
18 mg/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
0.8 mg/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
142 mEq/L
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
4.1 mEq/L
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
111 mEq/L
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
26 mEq/L
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
109 mm Hg
************************************************************************************************************************************************
[**2100-11-1**] 04:35
AM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
38 mm Hg
************************************************************************************************************************************************
[**2100-11-1**] 04:35
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
7.48 units
************************************************************************************************************************************************
[**2100-11-1**] 04:35
AM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
) arterial
************************************************************************************************************************************************
29 mEq/L
************************************************************************************************************************************************
[**2100-11-1**] 04:35
AM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
3.8 g/dL
************************************************************************************************************************************************
[**2100-10-30**] 03:27
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
8.9 mg/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
2.5 mg/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Ionized Calcium
ENTITY
************************************************************************************************************************************************
1.22 mmol/L
************************************************************************************************************************************************
[**2100-10-31**] 02:41
AM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
2.3 mg/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Phenytoin
ENTITY
(
Dilantin
ENTITY
)
************************************************************************************************************************************************
10.1 ug/mL
************************************************************************************************************************************************
[**2100-10-31**] 02:34
AM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
12.1
K/uL
ENTITY
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
11.9 g/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
33.9 %
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
Replete
ENTITY
with
fiber
ENTITY
Full
************************************************************************************************************************************************
strength;
Goal rate
ENTITY
: 65 ml/hr
************************************************************************************************************************************************
Residual Check
ENTITY
: q4h Hold
feeding
ENTITY
for
residual
ENTITY
>= : 200 ml
************************************************************************************************************************************************
GI
ENTITY
:
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
At
risk
ENTITY
for
malnutrition
ENTITY
************************************************************************************************************************************************
Pt
ENTITY
at
risk
ENTITY
due to:
NPO
ENTITY
/
hypocaloric diet
ENTITY
************************************************************************************************************************************************
Estimated Nutritional Needs
ENTITY
************************************************************************************************************************************************
Calories
ENTITY
:
[**2027**]-2200
ENTITY
(
BEE
ENTITY
x or / 22-25 cal/kg)
************************************************************************************************************************************************
Protein
ENTITY
: 114 (1.3 g/kg)
************************************************************************************************************************************************
Fluid
ENTITY
:
************************************************************************************************************************************************
Estimation
ENTITY
of previous
intake
ENTITY
:
Adequate
ENTITY
************************************************************************************************************************************************
Estimation
ENTITY
of
current
ENTITY
intake
ENTITY
:
Inadequate
ENTITY
************************************************************************************************************************************************
Specifics
ENTITY
:
************************************************************************************************************************************************
72 yo
male
ENTITY
s/p
ENTITY
witnessed fall w/
head trauma
ENTITY
,
right parietal-occipital
ENTITY
************************************************************************************************************************************************
SAH
ENTITY
w/
left intraparenchymal bleed
ENTITY
/
contre-coup injury
ENTITY
.
Pt
ENTITY
started on
************************************************************************************************************************************************
TF yesterday, currently
tol
ENTITY
goal TF
ENTITY
without
issue
ENTITY
,
per chart
ENTITY
, pt with +
************************************************************************************************************************************************
gag
ENTITY
, will plan to
extubate
ENTITY
this am. If unable to
extubate
ENTITY
, will need
************************************************************************************************************************************************
to change
TF
ENTITY
to better meet pt's
needs
ENTITY
.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
Tube
ENTITY
feeding
ENTITY
recommendations
ENTITY
:
************************************************************************************************************************************************
Check chemistry
ENTITY
10 panel
daily
ENTITY
and
replete
ENTITY
************************************************************************************************************************************************
Cont
ENTITY
Bg
ENTITY
management
ENTITY
************************************************************************************************************************************************
Pplease page
ENTITY
[**Numeric Identifier 1550**] if has ?
************************************************************************************************************************************************
"
************************************************************************************************************************************************
61565,Nutrition,"Objective
************************************************************************************************************************************************
Height
ENTITY
************************************************************************************************************************************************
Admit weight
ENTITY
************************************************************************************************************************************************
Daily weight
ENTITY
************************************************************************************************************************************************
Weight change
ENTITY
************************************************************************************************************************************************
BMI
ENTITY
************************************************************************************************************************************************
178 cm est.
************************************************************************************************************************************************
88.2 kg
************************************************************************************************************************************************
27.8
************************************************************************************************************************************************
Ideal body weight
ENTITY
************************************************************************************************************************************************
%
Ideal body weight
ENTITY
************************************************************************************************************************************************
Adjusted
ENTITY
weight
************************************************************************************************************************************************
Usual body weight
ENTITY
************************************************************************************************************************************************
%
Usual body weight
ENTITY
************************************************************************************************************************************************
75.3 kg
************************************************************************************************************************************************
117%
************************************************************************************************************************************************
Diagnosis
ENTITY
:
Head Bleed
ENTITY
************************************************************************************************************************************************
PMH
ENTITY
:
DM
ENTITY
,
HTN
ENTITY
************************************************************************************************************************************************
Food allergies
ENTITY
and
intolerances
ENTITY
:
************************************************************************************************************************************************
Pertinent medications
ENTITY
:
Esmolol
ENTITY
,
famotidine
ENTITY
,
colace
ENTITY
,
lytes
ENTITY
ss,
dilantin
ENTITY
,
************************************************************************************************************************************************
ssri
ENTITY
, others noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
143 mg/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Glucose Finger
ENTITY
Stick
************************************************************************************************************************************************
155
************************************************************************************************************************************************
[**2100-11-1**] 02:00
AM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
18 mg/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
0.8 mg/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
142 mEq/L
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
4.1 mEq/L
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
111 mEq/L
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
26 mEq/L
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
109 mm Hg
************************************************************************************************************************************************
[**2100-11-1**] 04:35
AM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
38 mm Hg
************************************************************************************************************************************************
[**2100-11-1**] 04:35
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
7.48 units
************************************************************************************************************************************************
[**2100-11-1**] 04:35
AM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
) arterial
************************************************************************************************************************************************
29 mEq/L
************************************************************************************************************************************************
[**2100-11-1**] 04:35
AM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
3.8 g/dL
************************************************************************************************************************************************
[**2100-10-30**] 03:27
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
8.9 mg/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
2.5 mg/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Ionized Calcium
ENTITY
************************************************************************************************************************************************
1.22 mmol/L
************************************************************************************************************************************************
[**2100-10-31**] 02:41
AM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
2.3 mg/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Phenytoin
ENTITY
(
Dilantin
ENTITY
)
************************************************************************************************************************************************
10.1 ug/mL
************************************************************************************************************************************************
[**2100-10-31**] 02:34
AM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
12.1
K/uL
ENTITY
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
11.9 g/dL
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
33.9 %
************************************************************************************************************************************************
[**2100-11-1**] 02:37
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
Replete
ENTITY
with
fiber
ENTITY
Full
************************************************************************************************************************************************
strength;
Goal rate
ENTITY
: 65 ml/hr (1560kcal/96.7g pro)
************************************************************************************************************************************************
Residual Check
ENTITY
: q4h Hold
feeding
ENTITY
for
residual
ENTITY
>= : 200 ml
************************************************************************************************************************************************
GI
ENTITY
:
Soft
ENTITY
,
Non-distended
ENTITY
,
Non-tender
ENTITY
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
At
risk
ENTITY
for
malnutrition
ENTITY
************************************************************************************************************************************************
Pt
ENTITY
at
risk
ENTITY
due to:
NPO
ENTITY
************************************************************************************************************************************************
Estimated Nutritional Needs
ENTITY
************************************************************************************************************************************************
Calories
ENTITY
: 1760-2200 (
BEE
ENTITY
x or / 20-25 cal/kg)
************************************************************************************************************************************************
Protein
ENTITY
: 114 (1.3 g/kg)
************************************************************************************************************************************************
Fluid
ENTITY
: per team
************************************************************************************************************************************************
Estimation
ENTITY
of previous
intake
ENTITY
: likely
adequate
ENTITY
************************************************************************************************************************************************
Estimation
ENTITY
of
current
ENTITY
intake
ENTITY
:
Inadequate
ENTITY
************************************************************************************************************************************************
Specifics
ENTITY
:
************************************************************************************************************************************************
72 yo
male
ENTITY
s/p
ENTITY
witnessed fall w/
head trauma
ENTITY
,
right parietal-occipital
ENTITY
************************************************************************************************************************************************
SAH
ENTITY
w/
left intraparenchymal bleed
ENTITY
/
contre-coup injury
ENTITY
.
Pt
ENTITY
started on
************************************************************************************************************************************************
TF yesterday, currently
tol
ENTITY
goal TF
ENTITY
without
issue
ENTITY
,
per chart
ENTITY
, pt with +
************************************************************************************************************************************************
gag
ENTITY
,
cough
ENTITY
, [**Last Name (
LF
ENTITY
) 1080**], [**First
Name3
ENTITY
(LF) **]
plan
ENTITY
to
extubate
ENTITY
this am. If unable to
************************************************************************************************************************************************
extubate
ENTITY
, will need to change
TF
ENTITY
to better meet pt's
needs
ENTITY
.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
Tube
ENTITY
feeding
ENTITY
recommendations
ENTITY
:
increase
ENTITY
TF
ENTITY
to
Replete
ENTITY
with
Fiber
ENTITY
goal
ENTITY
************************************************************************************************************************************************
75ml/hr (1800kcal/112g pro)
************************************************************************************************************************************************
Check chemistry
ENTITY
10 panel
daily
ENTITY
and replete
prn
ENTITY
************************************************************************************************************************************************
Cont
ENTITY
Bg
ENTITY
management
ENTITY
************************************************************************************************************************************************
Please page
ENTITY
[**Numeric Identifier 1550**] if has ?
************************************************************************************************************************************************
"
************************************************************************************************************************************************
61565,Nutrition,"Objective
************************************************************************************************************************************************
Pertinent
medications
ENTITY
:
pepcid
ENTITY
,
Heparin
ENTITY
,
docusate
ENTITY
,
Abx
ENTITY
,
RISS
ENTITY
, others
************************************************************************************************************************************************
noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
128 mg/dL
************************************************************************************************************************************************
[**2100-11-5**] 03:32
AM
ENTITY
************************************************************************************************************************************************
Glucose Finger
ENTITY
Stick
************************************************************************************************************************************************
140
************************************************************************************************************************************************
[**2100-11-4**] 08:00
PM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
18 mg/dL
************************************************************************************************************************************************
[**2100-11-5**] 03:32
AM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
0.7 mg/dL
************************************************************************************************************************************************
[**2100-11-5**] 03:32
AM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
140 mEq/L
************************************************************************************************************************************************
[**2100-11-5**] 03:32
AM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
3.9 mEq/L
************************************************************************************************************************************************
[**2100-11-5**] 03:32
AM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
103 mEq/L
************************************************************************************************************************************************
[**2100-11-5**] 03:32
AM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
28 mEq/L
************************************************************************************************************************************************
[**2100-11-5**] 03:32
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
94.[**Numeric Identifier 126**] mm Hg
************************************************************************************************************************************************
[**2100-11-5**] 07:26
AM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
37 mm Hg
************************************************************************************************************************************************
[**2100-11-5**] 07:26
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
7.49 units
************************************************************************************************************************************************
[**2100-11-5**] 07:26
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
urine
ENTITY
)
************************************************************************************************************************************************
7.0 units
************************************************************************************************************************************************
[**2100-11-5**] 11:05
AM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
) arterial
************************************************************************************************************************************************
29 mEq/L
************************************************************************************************************************************************
[**2100-11-5**] 07:26
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
8.7 mg/dL
************************************************************************************************************************************************
[**2100-11-4**] 02:31
AM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
3.0 mg/dL
************************************************************************************************************************************************
[**2100-11-4**] 02:31
AM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
2.3 mg/dL
************************************************************************************************************************************************
[**2100-11-4**] 02:31
AM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
12.2
K/uL
ENTITY
************************************************************************************************************************************************
[**2100-11-5**] 03:32
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
12.0 g/dL
************************************************************************************************************************************************
[**2100-11-5**] 03:32
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
33.8 %
************************************************************************************************************************************************
[**2100-11-5**] 03:32
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
Replete
ENTITY
c/ Fiber @65mL/hr (1560
************************************************************************************************************************************************
kcals/97 gr aa)
************************************************************************************************************************************************
GI
ENTITY
: Abd:
soft/+bs
ENTITY
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
Estimation
ENTITY
of
current
ENTITY
intake
ENTITY
:
Inadequate
ENTITY
************************************************************************************************************************************************
Specifics
ENTITY
:
************************************************************************************************************************************************
Pt s/p
ENTITY
trach/PEG/and
IVC
ENTITY
filter yesterday. TF
************************************************************************************************************************************************
s currently
infusing
ENTITY
@
************************************************************************************************************************************************
10mL/hr. Current
goal
ENTITY
Rx will meet 88%
estimated kcal
ENTITY
and 85% estimated
************************************************************************************************************************************************
aa needs therefore, will need to
increase
ENTITY
goal rate
ENTITY
of
TF
ENTITY
************************************************************************************************************************************************
s to avoid
************************************************************************************************************************************************
underfeeding
ENTITY
. .
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
Multivitamin
ENTITY
/
Mineral supplement
ENTITY
:
vua TF
ENTITY
************************************************************************************************************************************************
Tube
ENTITY
feeding
ENTITY
recommendations
ENTITY
:
Increase
ENTITY
TF goal
rate
ENTITY
to 75 mL/hr (1800
************************************************************************************************************************************************
kcals/112 gr aa
ENTITY
)
************************************************************************************************************************************************
BG
ENTITY
management
ENTITY
as you are
************************************************************************************************************************************************
Please
page
ENTITY
c/?'s #[**Numeric Identifier 1684**]
************************************************************************************************************************************************
"
************************************************************************************************************************************************
98851,Nutrition,"Patient has been
NPO
ENTITY
and/or on unsupplemented clear liquid diet for 1
************************************************************************************************************************************************
days
ENTITY
. If
patient's
ENTITY
diet
ENTITY
is not able to be
advanced
ENTITY
and
tolerated
ENTITY
,
************************************************************************************************************************************************
[**Street Address(1) 1511**] for
nutrition support
ENTITY
************************************************************************************************************************************************
Potential
ENTITY
for
nutrition risk
ENTITY
.
Patient
ENTITY
being
monitored
ENTITY
. Current
************************************************************************************************************************************************
intervention
ENTITY
if any, listed below:
************************************************************************************************************************************************
Comments
ENTITY
:
************************************************************************************************************************************************
Pt s/p LRRT [**4
ENTITY
-17**],
c/b hypoxia
ENTITY
and
increased
ENTITY
O2
ENTITY
requirements
ENTITY
in
PACU
ENTITY
, on
************************************************************************************************************************************************
clears
ENTITY
, tolerating well.
Clinically improving
ENTITY
, possibly transfer to
************************************************************************************************************************************************
floor
ENTITY
soon.
************************************************************************************************************************************************
If unable to
advance diet
ENTITY
further in 24-48hrs,
patient
ENTITY
may benefit from
************************************************************************************************************************************************
nutrition support
ENTITY
.
************************************************************************************************************************************************
Will f/u with
progress
ENTITY
, po
tolerance
ENTITY
.
************************************************************************************************************************************************
Please page w/
questions
ENTITY
#[**Numeric Identifier 1687**]
************************************************************************************************************************************************
12:11
************************************************************************************************************************************************
"
************************************************************************************************************************************************
58054,Nutrition,"Comments:
************************************************************************************************************************************************
Screening
ENTITY
per hospital nutrition protocol.
Noted
ENTITY
patient
ENTITY
is
comfort
ENTITY
************************************************************************************************************************************************
measures
ENTITY
only. No nutrition support indicated at this
time
ENTITY
. Will sign
************************************************************************************************************************************************
off. Please
consult
ENTITY
if needed. #[**Numeric Identifier 2337**]
************************************************************************************************************************************************
"
************************************************************************************************************************************************
99573,Nutrition,"Subjective
************************************************************************************************************************************************
patient
ENTITY
confused, unable to answer questions per chart
patient
ENTITY
had
************************************************************************************************************************************************
difficulty
ENTITY
swallowing
ENTITY
PTA d/t
damaged
ENTITY
salivary glands
ENTITY
from
XRT
ENTITY
************************************************************************************************************************************************
Objective
ENTITY
************************************************************************************************************************************************
Height
ENTITY
************************************************************************************************************************************************
Admit weight
ENTITY
************************************************************************************************************************************************
Daily weight
ENTITY
************************************************************************************************************************************************
Weight change
ENTITY
************************************************************************************************************************************************
BMI
ENTITY
************************************************************************************************************************************************
168 cm
************************************************************************************************************************************************
98.2 kg
************************************************************************************************************************************************
34.9
************************************************************************************************************************************************
Ideal body weight
ENTITY
************************************************************************************************************************************************
%
Ideal body weight
ENTITY
************************************************************************************************************************************************
Adjusted
ENTITY
weight
************************************************************************************************************************************************
Usual body weight
ENTITY
************************************************************************************************************************************************
%
Usual body weight
ENTITY
************************************************************************************************************************************************
59 kg
************************************************************************************************************************************************
166%
************************************************************************************************************************************************
68.8 kg
************************************************************************************************************************************************
Diagnosis
ENTITY
:
facial fx
ENTITY
************************************************************************************************************************************************
PMH
ENTITY
:
breast ca
ENTITY
,
tongue ca
ENTITY
,
ovarian ca
ENTITY
,
polymyalgia
ENTITY
,
NIDDM
ENTITY
,
vertigo
ENTITY
, hx
************************************************************************************************************************************************
of
falls
ENTITY
************************************************************************************************************************************************
Food allergies
ENTITY
and
intolerances
ENTITY
: none noted
************************************************************************************************************************************************
Pertinent
medications
ENTITY
:
RISS
ENTITY
, IV abx,
protonix
ENTITY
,
KCl
ENTITY
(30 mEq),
Dextrose
ENTITY
************************************************************************************************************************************************
5% 1/2
normal saline
ENTITY
with
KCl
ENTITY
, others noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
206
************************************************************************************************************************************************
[**2181-6-5**] 08:00
AM
ENTITY
************************************************************************************************************************************************
Glucose Finger
ENTITY
Stick
************************************************************************************************************************************************
222
************************************************************************************************************************************************
[**2181-6-4**] 08:00
PM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
11 mg/dL
************************************************************************************************************************************************
[**2181-6-4**] 11:36
PM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
0.5 mg/dL
************************************************************************************************************************************************
[**2181-6-4**] 11:36
PM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
134 mEq/L
************************************************************************************************************************************************
[**2181-6-4**] 11:36
PM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
4.1 mEq/L
************************************************************************************************************************************************
[**2181-6-5**] 09:13
AM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
98 mEq/L
************************************************************************************************************************************************
[**2181-6-4**] 11:36
PM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
26 mEq/L
************************************************************************************************************************************************
[**2181-6-4**] 11:36
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
urine
ENTITY
)
************************************************************************************************************************************************
6.5 units
************************************************************************************************************************************************
[**2181-6-3**] 12:30
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
8.5 mg/dL
************************************************************************************************************************************************
[**2181-6-4**] 11:36
PM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
2.3 mg/dL
************************************************************************************************************************************************
[**2181-6-4**] 11:36
PM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
2.0 mg/dL
************************************************************************************************************************************************
[**2181-6-4**] 11:36
PM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
9.2
K/uL
ENTITY
************************************************************************************************************************************************
[**2181-6-5**] 12:03
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
10.9 g/dL
************************************************************************************************************************************************
[**2181-6-5**] 12:03
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
32.7 %
************************************************************************************************************************************************
[**2181-6-5**] 12:03
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
NPO
ENTITY
************************************************************************************************************************************************
GI
ENTITY
:
obese
ENTITY
, +
bowel sounds
ENTITY
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
Obese
ENTITY
, At
risk
ENTITY
for
malnutrition
ENTITY
************************************************************************************************************************************************
Pt
ENTITY
at
risk
ENTITY
due to:
NPO
ENTITY
/
hypocaloric diet
ENTITY
,
trauma
ENTITY
************************************************************************************************************************************************
Estimated Nutritional Needs
ENTITY
based on adjusted
body
ENTITY
wt
************************************************************************************************************************************************
Calories
ENTITY
: 1513-1720 (22-25 cal/kg)
************************************************************************************************************************************************
Protein
ENTITY
: 83-103 (1.2-1.5 g/kg)
************************************************************************************************************************************************
Fluid
ENTITY
: per team
************************************************************************************************************************************************
Estimation
ENTITY
of previous
intake
ENTITY
: unknown
************************************************************************************************************************************************
Estimation
ENTITY
of
current
ENTITY
intake
ENTITY
:
Inadequate
ENTITY
d/t
NPO
ENTITY
status
ENTITY
************************************************************************************************************************************************
Specifics
ENTITY
: 78
year
ENTITY
old
female
ENTITY
admitted
ENTITY
from outside
hospital S/P
ENTITY
fall
************************************************************************************************************************************************
at
home
ENTITY
with
multiple injuries
ENTITY
including
Le Forte fx
ENTITY
,
multiple
ENTITY
sinus
ENTITY
************************************************************************************************************************************************
fx
ENTITY
,
orbital fx
ENTITY
,
facial
ENTITY
and
tongue swelling
ENTITY
.
Patient
ENTITY
seen by
SLP
ENTITY
on
[**6-4**
ENTITY
]
************************************************************************************************************************************************
who recommended
patient
ENTITY
remain
NPO
ENTITY
. If
patient
ENTITY
************************************************************************************************************************************************
s
diet
ENTITY
cannot be
************************************************************************************************************************************************
advanced
ENTITY
consider
initiating
ENTITY
tube feedings
ENTITY
to prevent further
************************************************************************************************************************************************
nutritional decline
ENTITY
.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
If
diet
ENTITY
cannot be advanced recommend starting
tube feedings
ENTITY
start with
************************************************************************************************************************************************
Replete
ENTITY
with
Fiber
ENTITY
@ 15 ml/hr advance to
goal
ENTITY
of 65 ml/hr =1560
************************************************************************************************************************************************
kcals/97 g
protein
ENTITY
************************************************************************************************************************************************
Check residuals
ENTITY
q 4-6 hours hold if greater than 150 cc
************************************************************************************************************************************************
Monitor lytes
ENTITY
and
glucose
ENTITY
with
initiation
ENTITY
of
tube feeding
ENTITY
************************************************************************************************************************************************
Change to
non-dextrose IV fluids
ENTITY
once
tube feedings
ENTITY
started
************************************************************************************************************************************************
Implement
ENTITY
any
SLP
ENTITY
recs
************************************************************************************************************************************************
Will continue to follow page [**Numeric Identifier 1372**] with
questions
ENTITY
************************************************************************************************************************************************
"
************************************************************************************************************************************************
40461,Nutrition,"Subjective
************************************************************************************************************************************************
oriented
ENTITY
x1
************************************************************************************************************************************************
Objective
ENTITY
************************************************************************************************************************************************
Height
ENTITY
************************************************************************************************************************************************
Admit weight
ENTITY
************************************************************************************************************************************************
Daily weight
ENTITY
************************************************************************************************************************************************
Weight change
ENTITY
************************************************************************************************************************************************
BMI
ENTITY
************************************************************************************************************************************************
178 cm
************************************************************************************************************************************************
63 kg
************************************************************************************************************************************************
74.9 kg ([**2113-2-3**] 04:00
AM
ENTITY
)
************************************************************************************************************************************************
19.9
************************************************************************************************************************************************
Pertinent
medications
ENTITY
:
Ranitidine
ENTITY
,
Multi-vitamin
ENTITY
,
ABX
ENTITY
,
Folic Acid
ENTITY
,
************************************************************************************************************************************************
Thiamine
ENTITY
,
Coumadin
ENTITY
,
Lasix
ENTITY
,
Colace
ENTITY
(held),
KCl
ENTITY
(20mEq
repletion
ENTITY
x2),
************************************************************************************************************************************************
Magnesium sulfate
ENTITY
(2g
repletion
ENTITY
),
Heparin drip
ENTITY
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
105 mg/dL
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Glucose Finger
ENTITY
Stick
************************************************************************************************************************************************
127
************************************************************************************************************************************************
[**2113-2-3**] 12:00
PM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
25 mg/dL
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
1.8 mg/dL
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
142 mEq/L
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
3.9 mEq/L
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
110 mEq/L
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
25 mEq/L
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
65 mm Hg
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
48 mm Hg
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
30 mm Hg
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
33 mm Hg
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
7.46 units
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
7.43 units
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
urine
ENTITY
)
************************************************************************************************************************************************
5.5 units
************************************************************************************************************************************************
[**2113-2-1**] 07:16
AM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
) arterial
************************************************************************************************************************************************
22 mEq/L
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
)
venous
ENTITY
************************************************************************************************************************************************
23 mEq/L
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
2.1 g/dL
************************************************************************************************************************************************
[**2113-2-1**] 02:44
PM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
7.5 mg/dL
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
3.0 mg/dL
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Ionized Calcium
ENTITY
************************************************************************************************************************************************
1.08 mmol/L
************************************************************************************************************************************************
[**2113-1-30**] 11:46
AM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
2.3 mg/dL
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
ALT
ENTITY
************************************************************************************************************************************************
23 IU/L
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Alkaline Phosphate
ENTITY
************************************************************************************************************************************************
51 IU/L
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
AST
ENTITY
************************************************************************************************************************************************
24 IU/L
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Amylase
ENTITY
************************************************************************************************************************************************
40 IU/L
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Total
ENTITY
Bilirubin
ENTITY
************************************************************************************************************************************************
0.3 mg/dL
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Triglyceride
ENTITY
************************************************************************************************************************************************
120 mg/dL
************************************************************************************************************************************************
[**2113-1-25**] 03:36
AM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
9.3
K/uL
ENTITY
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
8.9 g/dL
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
27.0 %
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
Diet
ENTITY
:
NPO
ENTITY
************************************************************************************************************************************************
Calorie counts
ENTITY
: [**2-1**] - 17 - 18
************************************************************************************************************************************************
GI
ENTITY
:
soft
ENTITY
, (+)
bowel sounds
ENTITY
; 500ml
stool
ENTITY
today
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
Estimation
ENTITY
of
current
ENTITY
intake
ENTITY
:
Inadequate
ENTITY
************************************************************************************************************************************************
Specifics
ENTITY
:
************************************************************************************************************************************************
49
year
ENTITY
old
male
ENTITY
with
mitral valve endocarditis
ENTITY
,
preop stroke
ENTITY
s/p
MVR
ENTITY
************************************************************************************************************************************************
(29mm [**First
Name8
ENTITY
(NamePattern2) **] [**First Name4 (
NamePattern1
ENTITY
) 1104**] [**Last Name (
NamePattern1
ENTITY
) 1105**])
debridement
ENTITY
of
aortic valve [**1
ENTITY
-27**].
Patient
ENTITY
with
************************************************************************************************************************************************
prolonged
ENTITY
poor
ENTITY
po
************************************************************************************************************************************************
s during admit. Was on
ground solids
ENTITY
+
thin liquid
ENTITY
************************************************************************************************************************************************
diet
ENTITY
, refusing po
************************************************************************************************************************************************
s at times. s/p calories counts
************************************************************************************************************************************************
880 calories [**2-1**]
************************************************************************************************************************************************
and 270
calories
ENTITY
[**2-2**]. Seen for
video swallow
ENTITY
evaluation
ENTITY
this
AM
ENTITY
************************************************************************************************************************************************
SLP
ENTITY
recommend
NPO
ENTITY
. Per discussion with
PA
ENTITY
************************************************************************************************************************************************
plan for
PEG placement
ENTITY
as
************************************************************************************************************************************************
previously unable to place
NGT
ENTITY
and feel that
patient
ENTITY
will pull it out.
************************************************************************************************************************************************
Agree with
PEG
ENTITY
for
long term
ENTITY
nutrition support to prevent further
************************************************************************************************************************************************
nutritional decline
ENTITY
and
optimize
ENTITY
nutrition
ENTITY
for
post-op healing
ENTITY
.
Noted
ENTITY
************************************************************************************************************************************************
multiple
ENTITY
lyte
ENTITY
repletions
ENTITY
.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
Current
diet
ENTITY
/
nutrition support
ENTITY
is appropriate: continue
************************************************************************************************************************************************
NPO
ENTITY
per
SLP
ENTITY
recommendations
ENTITY
************************************************************************************************************************************************
o
SLP
ENTITY
follow up
ENTITY
when appropriate
************************************************************************************************************************************************
Tube
ENTITY
feeding
ENTITY
recommendations
ENTITY
: Agree with
PEG
ENTITY
************************************************************************************************************************************************
o Once
feeding tube
ENTITY
placed, recommend begin
Isosource
ENTITY
1.5 @
************************************************************************************************************************************************
20ml/hr, advance as
tolerated
ENTITY
to
goal
ENTITY
of 45ml/hr = 1620
calories
ENTITY
and
************************************************************************************************************************************************
73g
protein
ENTITY
************************************************************************************************************************************************
Check residuals, hold
tube feed
ENTITY
if greater than 200ml
************************************************************************************************************************************************
Multivitamin
ENTITY
/
Mineral supplement
ENTITY
: continue current
************************************************************************************************************************************************
Check chemistry
ENTITY
10 panel
daily
ENTITY
************************************************************************************************************************************************
o
Replete
ENTITY
lytes
ENTITY
PRN
ENTITY
************************************************************************************************************************************************
Will follow,
page
ENTITY
if questions *[**Numeric Identifier 606**]
************************************************************************************************************************************************
"
************************************************************************************************************************************************
40461,Nutrition,"Subjective
************************************************************************************************************************************************
Patient oob
ENTITY
,
tube feed running
ENTITY
at 40 ml/hr.
************************************************************************************************************************************************
Objective
ENTITY
************************************************************************************************************************************************
Pertinent
medications
ENTITY
: noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
119
************************************************************************************************************************************************
[**2113-2-8**] 08:00
AM
ENTITY
************************************************************************************************************************************************
Glucose Finger
ENTITY
Stick
************************************************************************************************************************************************
150
************************************************************************************************************************************************
[**2113-2-7**] 10:00
PM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
31 mg/dL
************************************************************************************************************************************************
[**2113-2-8**] 02:50
AM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
2.0 mg/dL
************************************************************************************************************************************************
[**2113-2-8**] 02:50
AM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
143 mEq/L
************************************************************************************************************************************************
[**2113-2-8**] 02:50
AM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
3.4 mEq/L
************************************************************************************************************************************************
[**2113-2-8**] 07:52
AM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
109 mEq/L
************************************************************************************************************************************************
[**2113-2-8**] 02:50
AM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
25 mEq/L
************************************************************************************************************************************************
[**2113-2-8**] 02:50
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
65 mm Hg
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
48 mm Hg
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
30 mm Hg
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
33 mm Hg
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
7.46 units
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
7.43 units
************************************************************************************************************************************************
[**2113-2-7**] 05:19
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
urine
ENTITY
)
************************************************************************************************************************************************
5.5 units
************************************************************************************************************************************************
[**2113-2-1**] 07:16
AM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
) arterial
************************************************************************************************************************************************
22 mEq/L
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
)
venous
ENTITY
************************************************************************************************************************************************
23 mEq/L
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
2.2 g/dL
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
7.8 mg/dL
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
4.0 mg/dL
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Ionized Calcium
ENTITY
************************************************************************************************************************************************
1.07 mmol/L
************************************************************************************************************************************************
[**2113-2-7**] 05:19
PM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
2.1 mg/dL
************************************************************************************************************************************************
[**2113-2-8**] 07:52
AM
ENTITY
************************************************************************************************************************************************
ALT
ENTITY
************************************************************************************************************************************************
21 IU/L
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Alkaline Phosphate
ENTITY
************************************************************************************************************************************************
50 IU/L
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
AST
ENTITY
************************************************************************************************************************************************
23 IU/L
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Amylase
ENTITY
************************************************************************************************************************************************
45 IU/L
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Total
ENTITY
Bilirubin
ENTITY
************************************************************************************************************************************************
0.4 mg/dL
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Triglyceride
ENTITY
************************************************************************************************************************************************
120 mg/dL
************************************************************************************************************************************************
[**2113-1-25**] 03:36
AM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
10.1
K/uL
ENTITY
************************************************************************************************************************************************
[**2113-2-8**] 02:50
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
8.3 g/dL
************************************************************************************************************************************************
[**2113-2-8**] 02:50
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
26.1 %
************************************************************************************************************************************************
[**2113-2-8**] 02:50
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
Replete
ENTITY
with
fiber
ENTITY
Full
************************************************************************************************************************************************
strength
ENTITY
;
************************************************************************************************************************************************
Starting
rate
ENTITY
: 40 ml/hr;
Advance rate
ENTITY
by 20 ml q6h
Goal rate
ENTITY
: 70 ml/hr
************************************************************************************************************************************************
Residual Check
ENTITY
: q4h Hold
feeding
ENTITY
for
residual
ENTITY
>= : 200 ml
************************************************************************************************************************************************
Flush
ENTITY
w/ 30 ml
water
ENTITY
q8h
************************************************************************************************************************************************
GI
ENTITY
:
Abdominal
ENTITY
:
Soft
ENTITY
, Non-distended,
Non-tender
ENTITY
,
Bowel sounds
ENTITY
present,
************************************************************************************************************************************************
PEG site
ENTITY
clean
ENTITY
and
dry
ENTITY
.
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
49
year
ENTITY
old
male
ENTITY
s/p
PEG placement yesterday
ENTITY
,
tube feed
ENTITY
started
************************************************************************************************************************************************
yesterday
ENTITY
,
tolerated
ENTITY
Isosource
ENTITY
1.5 well,
tube feed ordered
ENTITY
changed
ENTITY
to
************************************************************************************************************************************************
Replete
ENTITY
with
fiber
ENTITY
this
morning
ENTITY
,
spoke
ENTITY
to team, does not want
patient
ENTITY
************************************************************************************************************************************************
on
special tube feed
ENTITY
, recommend change to
Fibersource
ENTITY
HN
ENTITY
as current
************************************************************************************************************************************************
formula
ENTITY
provides
excess
ENTITY
amount
ENTITY
of
protein
ENTITY
.
Noted discharge
ENTITY
planning in
************************************************************************************************************************************************
progress
ENTITY
.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
Tube
ENTITY
feeding
ENTITY
:
Fibersource
ENTITY
HN
ENTITY
goal
ENTITY
60ml/hr ( 1728kcal/76g
************************************************************************************************************************************************
protein)
************************************************************************************************************************************************
Check chemistry
ENTITY
10 panel
daily
ENTITY
, replete prn
************************************************************************************************************************************************
Continue
BS
ENTITY
management
ENTITY
************************************************************************************************************************************************
[**Numeric Identifier 943**] if has question
************************************************************************************************************************************************
"
************************************************************************************************************************************************
40461,Nutrition,"Subjective
************************************************************************************************************************************************
Patient asleep
ENTITY
.
************************************************************************************************************************************************
Objective
ENTITY
************************************************************************************************************************************************
Height
ENTITY
************************************************************************************************************************************************
Admit weight
ENTITY
************************************************************************************************************************************************
Daily weight
ENTITY
************************************************************************************************************************************************
Weight change
ENTITY
************************************************************************************************************************************************
BMI
ENTITY
************************************************************************************************************************************************
178 cm
************************************************************************************************************************************************
63 kg
************************************************************************************************************************************************
70.8 kg ([**2113-2-7**] 04:00
AM
ENTITY
)
************************************************************************************************************************************************
19.9
************************************************************************************************************************************************
Pertinent
medications
ENTITY
:
Multiple
ENTITY
Vitamins
ENTITY
,
Furosemide
ENTITY
,
Docusate Sodium
ENTITY
,
************************************************************************************************************************************************
others noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
157 mg/dL
************************************************************************************************************************************************
[**2113-2-7**] 04:00
AM
ENTITY
************************************************************************************************************************************************
Glucose Finger
ENTITY
Stick
************************************************************************************************************************************************
158
************************************************************************************************************************************************
[**2113-2-7**] 06:00
AM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
33 mg/dL
************************************************************************************************************************************************
[**2113-2-7**] 04:00
AM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
1.9 mg/dL
************************************************************************************************************************************************
[**2113-2-7**] 04:00
AM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
145 mEq/L
************************************************************************************************************************************************
[**2113-2-7**] 04:00
AM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
3.7 mEq/L
************************************************************************************************************************************************
[**2113-2-7**] 04:00
AM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
111 mEq/L
************************************************************************************************************************************************
[**2113-2-7**] 04:00
AM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
24 mEq/L
************************************************************************************************************************************************
[**2113-2-7**] 04:00
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
65 mm Hg
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
48 mm Hg
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
30 mm Hg
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
33 mm Hg
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
7.46 units
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
7.43 units
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
urine
ENTITY
)
************************************************************************************************************************************************
5.5 units
************************************************************************************************************************************************
[**2113-2-1**] 07:16
AM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
) arterial
************************************************************************************************************************************************
22 mEq/L
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
)
venous
ENTITY
************************************************************************************************************************************************
23 mEq/L
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
2.2 g/dL
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
7.8 mg/dL
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
4.0 mg/dL
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Ionized Calcium
ENTITY
************************************************************************************************************************************************
1.08 mmol/L
************************************************************************************************************************************************
[**2113-1-30**] 11:46
AM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
2.0 mg/dL
************************************************************************************************************************************************
[**2113-2-6**] 11:00
PM
ENTITY
************************************************************************************************************************************************
ALT
ENTITY
************************************************************************************************************************************************
21 IU/L
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Alkaline Phosphate
ENTITY
************************************************************************************************************************************************
50 IU/L
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
AST
ENTITY
************************************************************************************************************************************************
23 IU/L
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Amylase
ENTITY
************************************************************************************************************************************************
45 IU/L
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Total
ENTITY
Bilirubin
ENTITY
************************************************************************************************************************************************
0.4 mg/dL
************************************************************************************************************************************************
[**2113-2-6**] 04:05
AM
ENTITY
************************************************************************************************************************************************
Triglyceride
ENTITY
************************************************************************************************************************************************
120 mg/dL
************************************************************************************************************************************************
[**2113-1-25**] 03:36
AM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
12.3
K/uL
ENTITY
************************************************************************************************************************************************
[**2113-2-7**] 04:00
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
8.8 g/dL
************************************************************************************************************************************************
[**2113-2-7**] 04:00
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
26.9 %
************************************************************************************************************************************************
[**2113-2-7**] 04:00
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
Non-Standard
ENTITY
TPN
ENTITY
For
Date
ENTITY
:
************************************************************************************************************************************************
[**2113-2-6**] (1600ml, 270drextrose/80protein/35fat)
************************************************************************************************************************************************
Replete
ENTITY
with
fiber
ENTITY
Full strength;
************************************************************************************************************************************************
Starting
rate
ENTITY
: 10 ml/hr;
Advance rate
ENTITY
by 10 ml q6h
Goal rate
ENTITY
: 60 ml/hr
************************************************************************************************************************************************
Residual Check
ENTITY
: q4h Hold
feeding
ENTITY
for
residual
ENTITY
>= : 200 ml
************************************************************************************************************************************************
Flush
ENTITY
w/ 30 ml
water
ENTITY
q8h
************************************************************************************************************************************************
GI
ENTITY
:
Abdominal
ENTITY
:
Soft
ENTITY
, Non-distended,
Non-tender
ENTITY
,
Bowel sounds
ENTITY
present,
************************************************************************************************************************************************
PEG site
ENTITY
clean
ENTITY
and
dry
ENTITY
. Peg to
gravity drainage
ENTITY
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
49
year
ENTITY
old
male
ENTITY
with
Mitral valve endocarditis
ENTITY
,
preop stroke
ENTITY
s/p
MVR
ENTITY
************************************************************************************************************************************************
and
debridement
ENTITY
of
aortic valve [**
ENTITY
1-27**],
patient
ENTITY
failed S & S
evaluation
ENTITY
,
************************************************************************************************************************************************
TPN
ENTITY
started over the
weekend
ENTITY
while awaiting
PEG
ENTITY
.
PEG
ENTITY
placed
************************************************************************************************************************************************
yesterday
ENTITY
,
plan
ENTITY
to start
tube feeds
ENTITY
today,
current
ENTITY
tube feed
ENTITY
order not
************************************************************************************************************************************************
meeting
ENTITY
patient
ENTITY
************************************************************************************************************************************************
s estimated need.
Noted
ENTITY
patient
ENTITY
with
post
ENTITY
op fluid
************************************************************************************************************************************************
gain, recommend
fluid restricted formula
ENTITY
.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
Consider ordering day 1
TPN
ENTITY
tonight while slowly advancing
************************************************************************************************************************************************
tube feed
ENTITY
************************************************************************************************************************************************
Tube feeding
ENTITY
:
Isosource 1.5cal goal
ENTITY
45ml/hr ( 1620kcal/73g
************************************************************************************************************************************************
protein)
************************************************************************************************************************************************
Start tube
ENTITY
feed at 15ml/hr and
adv
ENTITY
slowly as
tol
ENTITY
************************************************************************************************************************************************
Check chemistry
ENTITY
10 panel
daily
ENTITY
, replete prn
************************************************************************************************************************************************
Continue
BS
ENTITY
management
ENTITY
************************************************************************************************************************************************
[**Numeric Identifier 943**] if has question
************************************************************************************************************************************************
"
************************************************************************************************************************************************
40461,Nutrition,"Subjective
************************************************************************************************************************************************
patient
ENTITY
sleeping
************************************************************************************************************************************************
Objective
ENTITY
************************************************************************************************************************************************
Height
ENTITY
************************************************************************************************************************************************
Admit weight
ENTITY
************************************************************************************************************************************************
Daily weight
ENTITY
************************************************************************************************************************************************
Weight change
ENTITY
************************************************************************************************************************************************
BMI
ENTITY
************************************************************************************************************************************************
178 cm
************************************************************************************************************************************************
63 kg
************************************************************************************************************************************************
74.9 kg ([**2113-2-3**] 04:00
AM
ENTITY
)
************************************************************************************************************************************************
19.9
************************************************************************************************************************************************
Pertinent
medications
ENTITY
:
D5 @10 ml/hr
ENTITY
,
KCl
ENTITY
(40 mEq
repletion
ENTITY
),
RISS
ENTITY
,
IV
ENTITY
************************************************************************************************************************************************
abx,
lansoprazole
ENTITY
,
famotidine
ENTITY
, others noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
73
************************************************************************************************************************************************
[**2113-2-4**] 12:00
PM
ENTITY
************************************************************************************************************************************************
Glucose Finger
ENTITY
Stick
************************************************************************************************************************************************
135
************************************************************************************************************************************************
[**2113-2-4**] 12:00 AM
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
25 mg/dL
************************************************************************************************************************************************
[**2113-2-4**] 03:42
AM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
1.6 mg/dL
************************************************************************************************************************************************
[**2113-2-4**] 03:42
AM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
140 mEq/L
************************************************************************************************************************************************
[**2113-2-4**] 03:42
AM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
3.5 mEq/L
************************************************************************************************************************************************
[**2113-2-4**] 03:42
AM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
108 mEq/L
************************************************************************************************************************************************
[**2113-2-4**] 03:42
AM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
22 mEq/L
************************************************************************************************************************************************
[**2113-2-4**] 03:42
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
65 mm Hg
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
48 mm Hg
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
30 mm Hg
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
33 mm Hg
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
7.46 units
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
7.43 units
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
urine
ENTITY
)
************************************************************************************************************************************************
5.5 units
************************************************************************************************************************************************
[**2113-2-1**] 07:16
AM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
) arterial
************************************************************************************************************************************************
22 mEq/L
************************************************************************************************************************************************
[**2113-1-31**] 04:47
AM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
)
venous
ENTITY
************************************************************************************************************************************************
23 mEq/L
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
2.1 g/dL
************************************************************************************************************************************************
[**2113-2-1**] 02:44
PM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
7.3 mg/dL
************************************************************************************************************************************************
[**2113-2-4**] 03:42
AM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
3.1 mg/dL
************************************************************************************************************************************************
[**2113-2-4**] 03:42
AM
ENTITY
************************************************************************************************************************************************
Ionized Calcium
ENTITY
************************************************************************************************************************************************
1.08 mmol/L
************************************************************************************************************************************************
[**2113-1-30**] 11:46
AM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
2.0 mg/dL
************************************************************************************************************************************************
[**2113-2-4**] 03:42
AM
ENTITY
************************************************************************************************************************************************
ALT
ENTITY
************************************************************************************************************************************************
23 IU/L
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Alkaline Phosphate
ENTITY
************************************************************************************************************************************************
51 IU/L
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
AST
ENTITY
************************************************************************************************************************************************
24 IU/L
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Amylase
ENTITY
************************************************************************************************************************************************
40 IU/L
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Total
ENTITY
Bilirubin
ENTITY
************************************************************************************************************************************************
0.3 mg/dL
************************************************************************************************************************************************
[**2113-2-3**] 05:24
AM
ENTITY
************************************************************************************************************************************************
Triglyceride
ENTITY
************************************************************************************************************************************************
120 mg/dL
************************************************************************************************************************************************
[**2113-1-25**] 03:36
AM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
13.4
K/uL
ENTITY
************************************************************************************************************************************************
[**2113-2-4**] 03:42
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
9.8 g/dL
************************************************************************************************************************************************
[**2113-2-4**] 03:42
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
29.7 %
************************************************************************************************************************************************
[**2113-2-4**] 03:42
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
NPO
ENTITY
************************************************************************************************************************************************
GI
ENTITY
:
soft
ENTITY
,
hypoactive bowel sounds
ENTITY
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
Specifics
ENTITY
:
Patient s/p video swallow
ENTITY
[**2-3**] which recommended
patient
ENTITY
be
************************************************************************************************************************************************
NPO
ENTITY
. Received
consult
ENTITY
for
PPN
ENTITY
recommendations
ENTITY
. Per discussion with
PA
ENTITY
,
************************************************************************************************************************************************
plan
ENTITY
is for
PEG placement
ENTITY
on
Monday
ENTITY
and to
supplement
ENTITY
nutrition
ENTITY
with
************************************************************************************************************************************************
parenteral nutrition
ENTITY
until
PEG
ENTITY
is able to be used.
Patient
ENTITY
with
PICC
ENTITY
,
************************************************************************************************************************************************
Day
ENTITY
1
TPN
ENTITY
ordered
ENTITY
to start tonight.
NGT
ENTITY
was attempted earlier in
week
ENTITY
************************************************************************************************************************************************
and was unable to placed and
team
ENTITY
thinks
patient
ENTITY
would pull it out.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
1.
Day
ENTITY
1
TPN
ENTITY
tonight
************************************************************************************************************************************************
2. Pending
glycemic control
ENTITY
advance to
goal
ENTITY
TPN
ENTITY
1.6L (270 g
************************************************************************************************************************************************
dextrose/80 g
amino
ENTITY
acids/35 g lipids)= 1588 kcals
************************************************************************************************************************************************
3.
Check
ENTITY
TG
ENTITY
hold
lipids
ENTITY
if greater than 400
************************************************************************************************************************************************
4. Once
PEG
ENTITY
placed start with
Isosource
ENTITY
HN
ENTITY
@ 15 ml/hr advance to
************************************************************************************************************************************************
goal
ENTITY
of 45 ml/hr = 1620 kcals/ 73 g
protein
ENTITY
************************************************************************************************************************************************
5. Will follow page [**Numeric Identifier 1372**] with
questions
ENTITY
************************************************************************************************************************************************
"
************************************************************************************************************************************************
40461,Nutrition,"Subjective
************************************************************************************************************************************************
Patient asleep
ENTITY
, [**
Name8
ENTITY
(
MD
ENTITY
) 77**]
RN
ENTITY
,
patient
ENTITY
refused all
po food
ENTITY
or
supplements
ENTITY
.
************************************************************************************************************************************************
Objective
ENTITY
************************************************************************************************************************************************
Height
ENTITY
************************************************************************************************************************************************
Admit weight
ENTITY
************************************************************************************************************************************************
Daily weight
ENTITY
************************************************************************************************************************************************
Weight change
ENTITY
************************************************************************************************************************************************
BMI
ENTITY
************************************************************************************************************************************************
178 cm
************************************************************************************************************************************************
63 kg
************************************************************************************************************************************************
70.5 kg ([**2113-1-19**] 08:00
AM
ENTITY
)
************************************************************************************************************************************************
up due to
fluid
ENTITY
************************************************************************************************************************************************
19.9
************************************************************************************************************************************************
Ideal body weight
ENTITY
************************************************************************************************************************************************
%
Ideal body weight
ENTITY
************************************************************************************************************************************************
Adjusted
ENTITY
weight
************************************************************************************************************************************************
Usual body weight
ENTITY
************************************************************************************************************************************************
%
Usual body weight
ENTITY
************************************************************************************************************************************************
75.3 kg
************************************************************************************************************************************************
119%
************************************************************************************************************************************************
63 kg
************************************************************************************************************************************************
100%
************************************************************************************************************************************************
Diagnosis
ENTITY
:
MITRAL VALVE
ENTITY
ENDOCARDITIS
************************************************************************************************************************************************
PMHx
ENTITY
: None -
no
ENTITY
medical care x 30
years
ENTITY
************************************************************************************************************************************************
Food allergies
ENTITY
and
intolerances
ENTITY
: not available
************************************************************************************************************************************************
Pertinent
medications
ENTITY
:
Furosemide
ENTITY
,
Milrinone
ENTITY
,
Multivitamins
ENTITY
,
Thiamine
ENTITY
,
************************************************************************************************************************************************
FoLIC Acid
ENTITY
,
Nicotine
ENTITY
Patch
ENTITY
,
Heparin
ENTITY
,
Docusate Sodium
ENTITY
,
Nafcillin
ENTITY
,
************************************************************************************************************************************************
Potassium Chloride
ENTITY
, others noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
117 mg/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
25 mg/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
1.5 mg/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
137 mEq/L
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
3.3 mEq/L
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
103 mEq/L
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
22 mEq/L
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
145 mm Hg
************************************************************************************************************************************************
[**2113-1-15**] 04:51
PM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
34 mm Hg
************************************************************************************************************************************************
[**2113-1-15**] 04:51
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
7.45 units
************************************************************************************************************************************************
[**2113-1-15**] 04:51
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
urine
ENTITY
)
************************************************************************************************************************************************
5.0 units
************************************************************************************************************************************************
[**2113-1-18**] 12:03
PM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
)
venous
ENTITY
************************************************************************************************************************************************
24 mEq/L
************************************************************************************************************************************************
[**2113-1-15**] 04:51
PM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
1.9 g/dL
************************************************************************************************************************************************
[**2113-1-18**] 07:15
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
7.1 mg/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
4.8 mg/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
1.9 mg/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
ALT
ENTITY
************************************************************************************************************************************************
36 IU/L
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Alkaline Phosphate
ENTITY
************************************************************************************************************************************************
44 IU/L
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
AST
ENTITY
************************************************************************************************************************************************
54 IU/L
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Total
ENTITY
Bilirubin
ENTITY
************************************************************************************************************************************************
0.4 mg/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
13.0
K/uL
ENTITY
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
11.8 g/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
35.2 %
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
Regular
ENTITY
;
Supplement
ENTITY
:
Ensure
ENTITY
************************************************************************************************************************************************
Plus breakfast
ENTITY
,
lunch
ENTITY
,
dinner
ENTITY
************************************************************************************************************************************************
GI
ENTITY
:
Abdominal
ENTITY
:
Soft
ENTITY
,
Non-tender
ENTITY
,
Bowel sounds
ENTITY
present
************************************************************************************************************************************************
Extremities
ENTITY
:
Right lower extremity edema
ENTITY
:
Absent
ENTITY
,
Left lower extremity
ENTITY
************************************************************************************************************************************************
edema
ENTITY
************************************************************************************************************************************************
Skin
ENTITY
: Warm,
Rash
ENTITY
:
upper
ENTITY
and lower ext,
occ petechiae
ENTITY
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
At
risk
ENTITY
for
malnutrition
ENTITY
************************************************************************************************************************************************
Patient
ENTITY
at
risk
ENTITY
due to:
Low
ENTITY
po
intake
ENTITY
, current
illness
ENTITY
, head CT showed
multipl
ENTITY
************************************************************************************************************************************************
e small
non-hemorrhagic
ENTITY
************************************************************************************************************************************************
infarcts
ENTITY
suspicious
ENTITY
for
septic emboli
ENTITY
,
************************************************************************************************************************************************
Estimated Nutritional Needs
ENTITY
************************************************************************************************************************************************
Calories
ENTITY
: 1575-1764 (
BEE
ENTITY
x or / 25-28 cal/kg)
************************************************************************************************************************************************
Protein
ENTITY
: 76-88 (1.2-1.4 g/kg)
************************************************************************************************************************************************
Fluid
ENTITY
: per team
************************************************************************************************************************************************
Calculations
ENTITY
based on:
Admit weight
ENTITY
************************************************************************************************************************************************
Estimation
ENTITY
of previous
intake
ENTITY
:
Inadequate
ENTITY
************************************************************************************************************************************************
Estimation
ENTITY
of
current
ENTITY
intake
ENTITY
:
Inadequate
ENTITY
************************************************************************************************************************************************
Specifics
ENTITY
:
************************************************************************************************************************************************
49
year
ENTITY
old
male
ENTITY
found to have
staphylococcus aureus
ENTITY
bacterial
ENTITY
************************************************************************************************************************************************
endocarditis
ENTITY
with
severe
ENTITY
mitral regurgitation [**3
ENTITY
-21**] mitral valve
************************************************************************************************************************************************
vegetations
ENTITY
and
flail leaflet
ENTITY
.
Patient transferred
ENTITY
from [**Hospital **] [**Hospital1 5**] for
CT surgery
ENTITY
evaluation
ENTITY
and further
management
ENTITY
.
************************************************************************************************************************************************
Patient
ENTITY
s/p speech and
swallow
ENTITY
evaluation
ENTITY
, okay to have
regular diet
ENTITY
,
************************************************************************************************************************************************
yet
patient
ENTITY
refused to take pos.
spoke
ENTITY
to team this
morning
ENTITY
, team
************************************************************************************************************************************************
considering
NGT
ENTITY
placement
ENTITY
.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
Po
ENTITY
as
tolerance
ENTITY
************************************************************************************************************************************************
Tube
ENTITY
feeding
ENTITY
recommendations
ENTITY
:
Nutren Pulmonary goal
ENTITY
45ml/hr
************************************************************************************************************************************************
(1620kcal/73.4g protein)
************************************************************************************************************************************************
Monitor tube feed tolerance
ENTITY
************************************************************************************************************************************************
Check chemistry
ENTITY
10 panel
daily
ENTITY
,
replete
ENTITY
as you are doing
************************************************************************************************************************************************
Consider adding
phos binder
ENTITY
if
serum phos
ENTITY
remains
elevated
ENTITY
************************************************************************************************************************************************
Start regular
ENTITY
insulin sliding scale if
serum glucose
ENTITY
greater
************************************************************************************************************************************************
than 150 mg/dL
************************************************************************************************************************************************
Other: [**Numeric Identifier 943**] if has question
************************************************************************************************************************************************
"
************************************************************************************************************************************************
40461,Nutrition,"Subjective
************************************************************************************************************************************************
Patient asleep
ENTITY
, [**
Name8
ENTITY
(
MD
ENTITY
) 77**]
RN
ENTITY
,
patient
ENTITY
refused all
po food
ENTITY
or
supplements
ENTITY
.
************************************************************************************************************************************************
Objective
ENTITY
************************************************************************************************************************************************
Height
ENTITY
************************************************************************************************************************************************
Admit weight
ENTITY
************************************************************************************************************************************************
Daily weight
ENTITY
************************************************************************************************************************************************
Weight change
ENTITY
************************************************************************************************************************************************
BMI
ENTITY
************************************************************************************************************************************************
178 cm
************************************************************************************************************************************************
63 kg
************************************************************************************************************************************************
70.5 kg ([**2113-1-19**] 08:00
AM
ENTITY
)
************************************************************************************************************************************************
up due to
fluid
ENTITY
************************************************************************************************************************************************
19.9
************************************************************************************************************************************************
Ideal body weight
ENTITY
************************************************************************************************************************************************
%
Ideal body weight
ENTITY
************************************************************************************************************************************************
Adjusted
ENTITY
weight
************************************************************************************************************************************************
Usual body weight
ENTITY
************************************************************************************************************************************************
%
Usual body weight
ENTITY
************************************************************************************************************************************************
75.3 kg
************************************************************************************************************************************************
119%
************************************************************************************************************************************************
63 kg
************************************************************************************************************************************************
100%
************************************************************************************************************************************************
Diagnosis
ENTITY
:
MITRAL VALVE
ENTITY
ENDOCARDITIS
************************************************************************************************************************************************
PMHx
ENTITY
: None -
no
ENTITY
medical care x 30
years
ENTITY
************************************************************************************************************************************************
Food allergies
ENTITY
and
intolerances
ENTITY
: not available
************************************************************************************************************************************************
Pertinent
medications
ENTITY
:
Furosemide
ENTITY
,
Milrinone
ENTITY
,
Multivitamins
ENTITY
,
Thiamine
ENTITY
,
************************************************************************************************************************************************
FoLIC Acid
ENTITY
,
Nicotine
ENTITY
Patch
ENTITY
,
Heparin
ENTITY
,
Docusate Sodium
ENTITY
,
Nafcillin
ENTITY
,
************************************************************************************************************************************************
Potassium Chloride
ENTITY
, others noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
117 mg/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
25 mg/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
1.5 mg/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
137 mEq/L
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
3.3 mEq/L
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
103 mEq/L
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
22 mEq/L
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
145 mm Hg
************************************************************************************************************************************************
[**2113-1-15**] 04:51
PM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
34 mm Hg
************************************************************************************************************************************************
[**2113-1-15**] 04:51
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
7.45 units
************************************************************************************************************************************************
[**2113-1-15**] 04:51
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
urine
ENTITY
)
************************************************************************************************************************************************
5.0 units
************************************************************************************************************************************************
[**2113-1-18**] 12:03
PM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
)
venous
ENTITY
************************************************************************************************************************************************
24 mEq/L
************************************************************************************************************************************************
[**2113-1-15**] 04:51
PM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
1.9 g/dL
************************************************************************************************************************************************
[**2113-1-18**] 07:15
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
7.1 mg/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
4.8 mg/dL
************************************************************************************************************************************************
[**2113-1-20**] 02:36
AM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
1.9 mg/dL
************************************************************************************************************************************************
IOPub message rate exceeded. The Jupyter server will temporarily stop sending output to the client in order to avoid crashing it. To change this limit, set the config variable `--ServerApp.iopub_msg_rate_limit`. Current values: ServerApp.iopub_msg_rate_limit=1000.0 (msgs/sec) ServerApp.rate_limit_window=3.0 (secs)
23 mEq/L
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
2.2 g/dL
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
7.6 mg/dL
************************************************************************************************************************************************
[**2113-2-1**] 03:30
AM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
4.6 mg/dL
************************************************************************************************************************************************
[**2113-2-1**] 03:30
AM
ENTITY
************************************************************************************************************************************************
Ionized Calcium
ENTITY
************************************************************************************************************************************************
1.08 mmol/L
************************************************************************************************************************************************
[**2113-1-30**] 11:46
AM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
2.2 mg/dL
************************************************************************************************************************************************
[**2113-2-1**] 03:30
AM
ENTITY
************************************************************************************************************************************************
ALT
ENTITY
************************************************************************************************************************************************
20 IU/L
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Alkaline Phosphate
ENTITY
************************************************************************************************************************************************
57 IU/L
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
AST
ENTITY
************************************************************************************************************************************************
26 IU/L
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Amylase
ENTITY
************************************************************************************************************************************************
17 IU/L
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Total
ENTITY
Bilirubin
ENTITY
************************************************************************************************************************************************
0.4 mg/dL
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Triglyceride
ENTITY
************************************************************************************************************************************************
120 mg/dL
************************************************************************************************************************************************
[**2113-1-25**] 03:36
AM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
18.2
K/uL
ENTITY
************************************************************************************************************************************************
[**2113-2-1**] 03:30
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
10.4 g/dL
************************************************************************************************************************************************
[**2113-2-1**] 03:30
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
31.5 %
************************************************************************************************************************************************
[**2113-2-1**] 03:30
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
Diet
ENTITY
:
Ground solids
ENTITY
, thin
************************************************************************************************************************************************
liquids
ENTITY
;
Ensure Pudding
ENTITY
and
Carnation Instant
ENTITY
Breakfast
ENTITY
with
meals
ENTITY
;
************************************************************************************************************************************************
calorie counts
ENTITY
[**2-1**], [**2-2**], [**2-3**]
************************************************************************************************************************************************
GI
ENTITY
:
soft
ENTITY
, (+)
bowel sounds
ENTITY
;
green liquid stool
ENTITY
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
Estimation
ENTITY
of
current
ENTITY
intake
ENTITY
:
Inadequate
ENTITY
************************************************************************************************************************************************
Specifics
ENTITY
:
************************************************************************************************************************************************
Patient
ENTITY
s/p
MVR
ENTITY
/
AVR
ENTITY
[**1-27**]. Extubated [**1-30**]. Seen by
SLP
ENTITY
[**1-31**] who
************************************************************************************************************************************************
recommended
ENTITY
above altered
consistency diet
ENTITY
with 1:1
supervision
ENTITY
. [**
Name8
ENTITY
(MD) **]
************************************************************************************************************************************************
RN
ENTITY
,
patient
ENTITY
took
Ensure pudding
ENTITY
and some
Carnation Instant
ENTITY
Breakfast
************************************************************************************************************************************************
shake
ENTITY
this
AM
ENTITY
with a lot of
encouragement
ENTITY
.
Patient
ENTITY
takes very small
************************************************************************************************************************************************
bites
ENTITY
and is a
picky eater
ENTITY
.
RN
ENTITY
reports wife
ENTITY
to bring in a list of
************************************************************************************************************************************************
foods
ENTITY
that
patient
ENTITY
likes.
Calorie counts
ENTITY
starting today.
Concerned
ENTITY
************************************************************************************************************************************************
with
nutrition status
ENTITY
given
poor
ENTITY
po
************************************************************************************************************************************************
s during admit (refusing po
************************************************************************************************************************************************
s at
************************************************************************************************************************************************
times), only received
tube feed
ENTITY
briefly on/off and
recent surgery
ENTITY
.
************************************************************************************************************************************************
Would strongly recommend
supplemental tube
ENTITY
feed to optimize
nutrition
ENTITY
************************************************************************************************************************************************
for
post-op
ENTITY
recovery
ENTITY
.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
Current
diet
ENTITY
/
nutrition support
ENTITY
is appropriate:
************************************************************************************************************************************************
Encourage/assist with
ENTITY
po
************************************************************************************************************************************************
o
Encourage wife
ENTITY
to bring in
food preference list
ENTITY
or
food
ENTITY
************************************************************************************************************************************************
o
Calorie counts
ENTITY
************************************************************************************************************************************************
please
record
ENTITY
on
kitchen
ENTITY
receipt
ENTITY
percent
************************************************************************************************************************************************
eaten
ENTITY
************************************************************************************************************************************************
Oral supplements
ENTITY
: Continue as ordered
************************************************************************************************************************************************
Multivitamin
ENTITY
/
Mineral supplement
ENTITY
: continue current
************************************************************************************************************************************************
Tube
ENTITY
feeding
ENTITY
recommendations
ENTITY
:
************************************************************************************************************************************************
o Consider placing
NGT
ENTITY
and
beginning tube
ENTITY
feeds
ENTITY
to supplement
************************************************************************************************************************************************
poor
ENTITY
po
************************************************************************************************************************************************
o Tube
feed goal
ENTITY
would be:
Nutren Pulmonary @ 45ml/hr
ENTITY
= 1620
************************************************************************************************************************************************
calories
ENTITY
and 73g
protein
ENTITY
************************************************************************************************************************************************
Check chemistry
ENTITY
10 panel
daily
ENTITY
************************************************************************************************************************************************
Will follow,
page
ENTITY
if questions *[**Numeric Identifier 606**]
************************************************************************************************************************************************
"
************************************************************************************************************************************************
40461,Nutrition,"Subjective
************************************************************************************************************************************************
just
extubated
ENTITY
************************************************************************************************************************************************
Objective
ENTITY
************************************************************************************************************************************************
Height
ENTITY
************************************************************************************************************************************************
Admit weight
ENTITY
************************************************************************************************************************************************
Daily weight
ENTITY
************************************************************************************************************************************************
Weight change
ENTITY
************************************************************************************************************************************************
BMI
ENTITY
************************************************************************************************************************************************
178 cm
************************************************************************************************************************************************
63 kg
************************************************************************************************************************************************
76.2 kg ([**2113-1-30**] 04:00
AM
ENTITY
)
************************************************************************************************************************************************
19.9
************************************************************************************************************************************************
Pertinent
medications
ENTITY
:
Multivitamins
ENTITY
, others noted
************************************************************************************************************************************************
Labs
ENTITY
:
************************************************************************************************************************************************
Value
ENTITY
************************************************************************************************************************************************
Date
************************************************************************************************************************************************
Glucose
ENTITY
************************************************************************************************************************************************
106 mg/dL
************************************************************************************************************************************************
[**2113-1-30**] 07:59
AM
ENTITY
************************************************************************************************************************************************
Glucose Finger
ENTITY
Stick
************************************************************************************************************************************************
93
************************************************************************************************************************************************
[**2113-1-29**] 06:00
PM
ENTITY
************************************************************************************************************************************************
BUN
ENTITY
************************************************************************************************************************************************
20 mg/dL
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Creatinine
ENTITY
************************************************************************************************************************************************
1.6 mg/dL
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Sodium
ENTITY
************************************************************************************************************************************************
137 mEq/L
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Potassium
ENTITY
************************************************************************************************************************************************
3.5 mEq/L
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Chloride
ENTITY
************************************************************************************************************************************************
104 mEq/L
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
TCO2
ENTITY
************************************************************************************************************************************************
22 mEq/L
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
85.[**Numeric Identifier 299**] mm Hg
************************************************************************************************************************************************
[**2113-1-30**] 09:19
AM
ENTITY
************************************************************************************************************************************************
PO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
48 mm Hg
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
33 mm Hg
************************************************************************************************************************************************
[**2113-1-30**] 09:19
AM
ENTITY
************************************************************************************************************************************************
PCO2
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
33 mm Hg
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
arterial
ENTITY
)
************************************************************************************************************************************************
7.41 units
************************************************************************************************************************************************
[**2113-1-30**] 09:19
AM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
venous
ENTITY
)
************************************************************************************************************************************************
7.43 units
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
pH
ENTITY
(
urine
ENTITY
)
************************************************************************************************************************************************
5.0 units
************************************************************************************************************************************************
[**2113-1-25**] 02:26
PM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
) arterial
************************************************************************************************************************************************
22 mEq/L
************************************************************************************************************************************************
[**2113-1-30**] 09:19
AM
ENTITY
************************************************************************************************************************************************
CO2
ENTITY
(
Calc
ENTITY
)
venous
ENTITY
************************************************************************************************************************************************
23 mEq/L
************************************************************************************************************************************************
[**2113-1-21**] 05:21
PM
ENTITY
************************************************************************************************************************************************
Albumin
ENTITY
************************************************************************************************************************************************
2.2 g/dL
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Calcium
ENTITY
non-ionized
ENTITY
************************************************************************************************************************************************
8.4 mg/dL
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Phosphorus
ENTITY
************************************************************************************************************************************************
5.2 mg/dL
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Ionized Calcium
ENTITY
************************************************************************************************************************************************
1.09 mmol/L
************************************************************************************************************************************************
[**2113-1-30**] 07:59
AM
ENTITY
************************************************************************************************************************************************
Magnesium
ENTITY
************************************************************************************************************************************************
2.1 mg/dL
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
ALT
ENTITY
************************************************************************************************************************************************
20 IU/L
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Alkaline Phosphate
ENTITY
************************************************************************************************************************************************
57 IU/L
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
AST
ENTITY
************************************************************************************************************************************************
26 IU/L
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Amylase
ENTITY
************************************************************************************************************************************************
17 IU/L
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Total
ENTITY
Bilirubin
ENTITY
************************************************************************************************************************************************
0.4 mg/dL
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Triglyceride
ENTITY
************************************************************************************************************************************************
120 mg/dL
************************************************************************************************************************************************
[**2113-1-25**] 03:36
AM
ENTITY
************************************************************************************************************************************************
WBC
ENTITY
************************************************************************************************************************************************
11.5
K/uL
ENTITY
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Hgb
ENTITY
************************************************************************************************************************************************
10.3 g/dL
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Hematocrit
ENTITY
************************************************************************************************************************************************
30.1 %
************************************************************************************************************************************************
[**2113-1-30**] 03:25
AM
ENTITY
************************************************************************************************************************************************
Current diet
ENTITY
order /
nutrition support
ENTITY
:
Nutren Pulmonary Full strength
ENTITY
;
************************************************************************************************************************************************
Starting
rate
ENTITY
: 10 ml/hr;
Advance rate
ENTITY
by 10 ml q4h
Goal rate
ENTITY
: 50 ml/hr
************************************************************************************************************************************************
Residual Check
ENTITY
: q4h Hold
feeding
ENTITY
for
residual
ENTITY
>= : 200 ml
************************************************************************************************************************************************
Flush
ENTITY
w/ 30 ml
water q4h
ENTITY
( not running)
************************************************************************************************************************************************
GI
ENTITY
:
soft
ENTITY
,
flesiseal
ENTITY
in place
************************************************************************************************************************************************
SKIN
ENTITY
:
stage 2 wounds
ENTITY
************************************************************************************************************************************************
Assessment
ENTITY
of
Nutritional Status
ENTITY
************************************************************************************************************************************************
49
year
ENTITY
old
male
ENTITY
admitted
ENTITY
on
[**1
ENTITY
-15**] with
endocarditis
ENTITY
s/p
MVR
ENTITY
and
aortic
ENTITY
************************************************************************************************************************************************
valve debridement
ENTITY
on
[**1
ENTITY
-27**],
patient
ENTITY
extubated
ENTITY
this
morning
ENTITY
.
Patient
ENTITY
************************************************************************************************************************************************
well known to me from
CCU
ENTITY
,
patient
ENTITY
with
minimal
ENTITY
nutrition
ENTITY
since
************************************************************************************************************************************************
hospital admission
ENTITY
(previously refused
po food
ENTITY
and
nutrition
ENTITY
************************************************************************************************************************************************
supplements
ENTITY
in the
ccu
ENTITY
, received 1
day
ENTITY
of
tube feed
ENTITY
prior to
OR
ENTITY
.
************************************************************************************************************************************************
Patient
ENTITY
at very high risk for
malnutrition
ENTITY
, highly recommend replace
************************************************************************************************************************************************
feeding tube
ENTITY
,
restart tube feed
ENTITY
as
temporary
ENTITY
nutrition support
ENTITY
for
post
ENTITY
************************************************************************************************************************************************
op
recovery
ENTITY
.
************************************************************************************************************************************************
Medical Nutrition Therapy
ENTITY
Plan
ENTITY
-
Recommend
ENTITY
the Following
************************************************************************************************************************************************
Adv diet
ENTITY
if remains medically stable
************************************************************************************************************************************************
Continue tube feed
ENTITY
as
supplemental nutrition support
ENTITY
:
goal
ENTITY
************************************************************************************************************************************************
Nutren Pulmonary goal
ENTITY
45ml/hr to provide 1620kcal/73.4g protein
************************************************************************************************************************************************
Phos binder
ENTITY
if
serum phos
ENTITY
remains
elevated
ENTITY
************************************************************************************************************************************************
Check chemistry
ENTITY
10 panel
daily
ENTITY
, replete prn
************************************************************************************************************************************************
BS
ENTITY
management
ENTITY
************************************************************************************************************************************************
Other: [**Numeric Identifier 943**]
************************************************************************************************************************************************
"
************************************************************************************************************************************************
In [45]:
df=notes
In [46]:
# Build corpus of all the entities extracted from the notes using spaCy model.
# The corpus is an array of arrays or list of lists where each of the nested lists corresponds to a note.
corpus=[]
for row in range(0, len(df)):
str_tokens=[]
tokens= nlp(df[row]).ents
for i in range(0, len(tokens)):
str_tokens.append(tokens[i].text)
corpus.append(list(str_tokens))
print(corpus)
[['SUBJECT_ID', 'CATEGORY'], ['MICU', 'aspiration', 'Diet'], ['NPO', 'NGT', 'medication', 'Noted', 'transition', 'comfort'], ['focused care'], ['Will sign', 'time', 'consult'], [], [], ['medications', 'RISS', 'SS', 'lytes', 'thiamin', 'folate', 'lasix', 'bowel'], ['regimen', 'MOM', 'reglan'], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['Glucose Finger'], [], ['AM'], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'arterial'], [], ['AM'], ['PCO2', 'arterial'], [], ['AM'], ['pH', 'arterial'], [], ['AM'], ['pH', 'urine'], [], ['PM'], ['CO2', 'Calc'], [], ['AM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Ionized Calcium'], [], ['PM'], ['Magnesium'], [], ['AM'], ['Current diet', 'nutrition support', 'Fibersource', 'HN@60mL/hr'], ['infusing'], ['GI', 'soft/+bs'], ['Assessment', 'Nutritional Status'], ['Specifics'], ['Pt', 'extubated', 'Pt', 'TF'], ['goal'], ['nutrition', 'Anticipate diet advancement'], [], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['Advance diet', 'team', 'swallow', 'eval', 's/s', 'aspiration'], ['advance diet', 'SLP-', 'NGT', "resume TF's"], [], ['plan', 'page'], [], [], ['intubated'], ['Objective'], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], [], ['Ideal body weight'], ['Ideal body weight'], ['Adjusted'], ['Usual body weight'], ['Usual body weight'], [], [], ['Diagnosis', 'S/P Fall'], ['PMH', 'etoh', 'smoker', 'cirrhosis'], ['Food allergies', 'intolerances', 'NKFA'], ['medications', 'fentanyl', 'LR', 'lasix', 'RISS', 'IV'], [], ['Labs'], ['Value'], [], ['Glucose'], [], ['PM'], ['Glucose Finger'], [], ['AM'], ['BUN'], [], ['PM'], ['Creatinine'], [], ['PM'], ['Sodium'], [], ['PM'], ['Potassium'], [], ['PM'], ['Chloride'], [], ['PM'], ['TCO2'], [], ['PM'], ['PO2', 'arterial'], [], ['AM'], ['PCO2', 'arterial'], [], ['AM'], ['pH', 'arterial'], [], ['AM'], ['pH', 'urine'], [], ['PM'], ['CO2', 'Calc'], [], ['AM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['PM'], ['Phosphorus'], [], ['PM'], ['Ionized Calcium'], [], ['AM'], ['Magnesium'], [], ['PM'], ['ALT'], [], ['AM'], ['Alkaline Phosphate'], [], ['AM'], ['AST'], [], ['AM'], ['Total', 'Bilirubin'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'NPO', 'replete', 'fiber'], [], ['GI', 'OGT'], ['Assessment', 'Nutritional Status'], ['risk', 'malnutrition'], ['Pt', 'risk', 'NPO', 'hypocaloric diet'], ['Estimated Nutritional Needs'], ['Calories'], ['Protein'], ['Fluid'], ['Estimation', 'intake', 'Adequate'], ['Estimation', 'current', 'intake', 'Inadequate'], ['Specifics', 'year', 'male', 'OSH', 'intubated', 'Pt'], ['S/P', 'CT', 'Stage IV splenic laceration', 'TF'], ['minimal residuals', 'Name8', 'RN', 'TF', 'kcals/89 g Pro'], ['Recommend', 'changing TF', 'nutritional'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['Check chemistry', 'daily'], ['Change', 'TF', 'goal', 'Fibersource', 'HN'], ['Pro'], ['Pls page'], [], [], ['intubated'], ['Objective'], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], [], ['Ideal body weight'], ['Ideal body weight'], ['Adjusted'], ['Usual body weight'], ['Usual body weight'], [], [], ['Diagnosis', 'S/P Fall'], ['PMH', 'etoh', 'smoker', 'cirrhosis'], ['Food allergies', 'intolerances', 'NKFA'], ['medications', 'fentanyl', 'LR', 'lasix', 'RISS', 'IV'], [], ['Labs'], ['Value'], [], ['Glucose'], [], ['PM'], ['Glucose Finger'], [], ['AM'], ['BUN'], [], ['PM'], ['Creatinine'], [], ['PM'], ['Sodium'], [], ['PM'], ['Potassium'], [], ['PM'], ['Chloride'], [], ['PM'], ['TCO2'], [], ['PM'], ['PO2', 'arterial'], [], ['AM'], ['PCO2', 'arterial'], [], ['AM'], ['pH', 'arterial'], [], ['AM'], ['pH', 'urine'], [], ['PM'], ['CO2', 'Calc'], [], ['AM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['PM'], ['Phosphorus'], [], ['PM'], ['Ionized Calcium'], [], ['AM'], ['Magnesium'], [], ['PM'], ['ALT'], [], ['AM'], ['Alkaline Phosphate'], [], ['AM'], ['AST'], [], ['AM'], ['Total', 'Bilirubin'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'NPO', 'replete', 'fiber'], [], ['GI', 'OGT'], ['Assessment', 'Nutritional Status'], ['risk', 'malnutrition'], ['Pt', 'risk', 'NPO', 'hypocaloric diet'], ['Estimated Nutritional Needs'], ['Calories'], ['Protein'], ['Fluid'], ['Estimation', 'intake', 'Adequate'], ['Estimation', 'current', 'intake', 'Inadequate'], ['Specifics', 'year', 'male', 'OSH', 'intubated', 'Pt'], ['S/P', 'CT', 'Stage IV splenic laceration', 'TF'], ['minimal residuals', 'Name8', 'RN', 'TF', 'kcals/89 g Pro'], ['Recommend', 'changing TF', 'nutritional'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['Check chemistry', 'daily'], ['Change', 'TF', 'goal', 'Fibersource', 'HN'], ['Pro'], ['Pls page'], [], [], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], [], ['Ideal body weight'], ['Ideal body weight'], ['Adjusted'], ['Usual body weight'], ['Usual body weight'], [], [], ['Diagnosis', 'Head Bleed'], ['PMH', 'DM'], ['Food allergies', 'intolerances'], ['Pertinent medications', 'Esmolol', 'famotidine', 'colace', 'lytes', 'dilantin'], ['ssri'], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['Glucose Finger'], [], ['AM'], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'arterial'], [], ['AM'], ['PCO2', 'arterial'], [], ['AM'], ['pH', 'arterial'], [], ['AM'], ['CO2', 'Calc'], [], ['AM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Ionized Calcium'], [], ['AM'], ['Magnesium'], [], ['AM'], ['Phenytoin', 'Dilantin'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'Replete', 'fiber'], ['Goal rate'], ['Residual Check', 'feeding', 'residual'], ['GI'], ['Assessment', 'Nutritional Status'], ['risk', 'malnutrition'], ['Pt', 'risk', 'NPO', 'hypocaloric diet'], ['Estimated Nutritional Needs'], ['Calories', '[**2027**]-2200', 'BEE'], ['Protein'], ['Fluid'], ['Estimation', 'intake', 'Adequate'], ['Estimation', 'current', 'intake', 'Inadequate'], ['Specifics'], ['male', 's/p', 'head trauma', 'right parietal-occipital\n'], ['SAH', 'left intraparenchymal bleed', 'contre-coup injury', 'Pt'], ['tol', 'goal TF', 'issue', 'per chart'], ['gag', 'extubate', 'extubate'], ['TF', 'needs'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['Tube', 'feeding', 'recommendations'], ['Check chemistry', 'daily', 'replete'], ['Cont', 'Bg', 'management'], ['Pplease page'], [], [], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], [], ['Ideal body weight'], ['Ideal body weight'], ['Adjusted'], ['Usual body weight'], ['Usual body weight'], [], [], ['Diagnosis', 'Head Bleed'], ['PMH', 'DM', 'HTN'], ['Food allergies', 'intolerances'], ['Pertinent medications', 'Esmolol', 'famotidine', 'colace', 'lytes', 'dilantin'], ['ssri'], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['Glucose Finger'], [], ['AM'], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'arterial'], [], ['AM'], ['PCO2', 'arterial'], [], ['AM'], ['pH', 'arterial'], [], ['AM'], ['CO2', 'Calc'], [], ['AM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Ionized Calcium'], [], ['AM'], ['Magnesium'], [], ['AM'], ['Phenytoin', 'Dilantin'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'Replete', 'fiber'], ['Goal rate'], ['Residual Check', 'feeding', 'residual'], ['GI', 'Soft', 'Non-distended', 'Non-tender'], ['Assessment', 'Nutritional Status'], ['risk', 'malnutrition'], ['Pt', 'risk', 'NPO'], ['Estimated Nutritional Needs'], ['Calories', 'BEE'], ['Protein'], ['Fluid'], ['Estimation', 'intake', 'adequate'], ['Estimation', 'current', 'intake', 'Inadequate'], ['Specifics'], ['male', 's/p', 'head trauma', 'right parietal-occipital\n'], ['SAH', 'left intraparenchymal bleed', 'contre-coup injury', 'Pt'], ['tol', 'goal TF', 'issue', 'per chart'], ['gag', 'cough', 'LF', 'Name3', 'plan', 'extubate'], ['extubate', 'TF', 'needs'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['Tube', 'feeding', 'recommendations', 'increase', 'TF', 'Replete', 'Fiber', 'goal'], [], ['Check chemistry', 'daily', 'prn'], ['Cont', 'Bg', 'management'], ['Please page'], [], [], ['medications', 'pepcid', 'Heparin', 'docusate', 'Abx', 'RISS'], [], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['Glucose Finger'], [], ['PM'], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'arterial'], [], ['AM'], ['PCO2', 'arterial'], [], ['AM'], ['pH', 'arterial'], [], ['AM'], ['pH', 'urine'], [], ['AM'], ['CO2', 'Calc'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Magnesium'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'Replete'], [], ['GI', 'soft/+bs'], ['Assessment', 'Nutritional Status'], ['Estimation', 'current', 'intake', 'Inadequate'], ['Specifics'], ['Pt s/p', 'IVC'], ['infusing'], ['goal', 'estimated kcal'], ['increase', 'goal rate', 'TF'], [], ['underfeeding'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['Multivitamin', 'Mineral supplement', 'vua TF'], ['Tube', 'feeding', 'recommendations', 'Increase', 'rate'], ['kcals/112 gr aa'], ['BG', 'management'], ['page'], [], ['NPO'], ['days', "patient's", 'diet', 'advanced', 'tolerated'], ['nutrition support'], ['Potential', 'nutrition risk', 'Patient', 'monitored'], ['intervention'], ['Comments'], ['Pt s/p LRRT [**4', 'c/b hypoxia', 'increased', 'O2', 'requirements', 'PACU'], ['clears', 'Clinically improving'], ['floor'], ['advance diet', 'patient'], ['nutrition support'], ['progress', 'tolerance'], ['questions'], [], [], [], ['Screening', 'Noted', 'patient', 'comfort'], ['measures', 'time'], ['consult'], [], [], ['patient', 'patient'], ['difficulty', 'swallowing', 'damaged', 'salivary glands', 'XRT'], ['Objective'], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], [], ['Ideal body weight'], ['Ideal body weight'], ['Adjusted'], ['Usual body weight'], ['Usual body weight'], [], [], [], ['Diagnosis', 'facial fx\n'], ['PMH', 'breast ca', 'tongue ca', 'ovarian ca', 'polymyalgia', 'NIDDM', 'vertigo'], ['falls'], ['Food allergies', 'intolerances'], ['medications', 'RISS', 'protonix', 'KCl', 'Dextrose'], ['normal saline', 'KCl'], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['Glucose Finger'], [], ['PM'], ['BUN'], [], ['PM'], ['Creatinine'], [], ['PM'], ['Sodium'], [], ['PM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['PM'], ['TCO2'], [], ['PM'], ['pH', 'urine'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['PM'], ['Phosphorus'], [], ['PM'], ['Magnesium'], [], ['PM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'NPO'], ['GI', 'obese', 'bowel sounds'], ['Assessment', 'Nutritional Status'], ['Obese', 'risk', 'malnutrition'], ['Pt', 'risk', 'NPO', 'hypocaloric diet', 'trauma'], ['Estimated Nutritional Needs', 'body'], ['Calories'], ['Protein'], ['Fluid'], ['Estimation', 'intake'], ['Estimation', 'current', 'intake', 'Inadequate', 'NPO', 'status'], ['Specifics', 'year', 'female', 'admitted', 'hospital S/P'], ['home', 'multiple injuries', 'Le Forte fx', 'multiple', 'sinus'], ['fx', 'orbital fx', 'facial', 'tongue swelling', 'Patient', 'SLP', '[**6-4**'], ['patient', 'NPO', 'patient'], ['diet'], ['advanced', 'initiating', 'tube feedings'], ['nutritional decline'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['diet', 'tube feedings'], ['Replete', 'Fiber', 'goal'], ['protein'], ['Check residuals'], ['Monitor lytes', 'glucose', 'initiation', 'tube feeding'], ['non-dextrose IV fluids', 'tube feedings'], ['Implement', 'SLP'], ['questions'], [], [], ['oriented'], ['Objective'], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], ['AM'], [], ['medications', 'Ranitidine', 'Multi-vitamin', 'ABX', 'Folic Acid'], ['Thiamine', 'Coumadin', 'Lasix', 'Colace', 'KCl', 'repletion'], ['Magnesium sulfate', 'repletion', 'Heparin drip'], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['Glucose Finger'], [], ['PM'], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'arterial'], [], ['AM'], ['PO2', 'venous'], [], ['PM'], ['PCO2', 'arterial'], [], ['AM'], ['PCO2', 'venous'], [], ['PM'], ['pH', 'arterial'], [], ['AM'], ['pH', 'venous'], [], ['PM'], ['pH', 'urine'], [], ['AM'], ['CO2', 'Calc'], [], ['AM'], ['CO2', 'Calc', 'venous'], [], ['PM'], ['Albumin'], [], ['PM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Ionized Calcium'], [], ['AM'], ['Magnesium'], [], ['AM'], ['ALT'], [], ['AM'], ['Alkaline Phosphate'], [], ['AM'], ['AST'], [], ['AM'], ['Amylase'], [], ['AM'], ['Total', 'Bilirubin'], [], ['AM'], ['Triglyceride'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'Diet', 'NPO'], ['Calorie counts'], ['GI', 'soft', 'bowel sounds', 'stool'], ['Assessment', 'Nutritional Status'], ['Estimation', 'current', 'intake', 'Inadequate'], ['Specifics'], ['year', 'male', 'mitral valve endocarditis', 'preop stroke', 'MVR'], ['Name8', 'NamePattern1', 'NamePattern1', 'debridement', 'aortic valve [**1', 'Patient'], ['prolonged', 'poor'], ['ground solids', 'thin liquid'], ['diet'], [], [], ['calories', 'video swallow', 'evaluation', 'AM'], ['SLP', 'NPO', 'PA'], ['PEG placement'], ['NGT', 'patient'], ['PEG', 'long term'], ['nutritional decline', 'optimize', 'nutrition', 'post-op healing', 'Noted'], ['multiple', 'lyte', 'repletions'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['diet', 'nutrition support'], ['NPO', 'SLP', 'recommendations'], ['SLP', 'follow up'], ['Tube', 'feeding', 'recommendations', 'PEG'], ['feeding tube', 'Isosource'], ['tolerated', 'goal', 'calories'], ['protein'], ['tube feed'], ['Multivitamin', 'Mineral supplement'], ['Check chemistry', 'daily'], ['Replete', 'lytes', 'PRN'], ['page'], [], [], ['Patient oob', 'tube feed running'], ['Objective'], ['medications'], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['Glucose Finger'], [], ['PM'], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'arterial'], [], ['AM'], ['PO2', 'venous'], [], ['PM'], ['PCO2', 'arterial'], [], ['AM'], ['PCO2', 'venous'], [], ['PM'], ['pH', 'arterial'], [], ['AM'], ['pH', 'venous'], [], ['PM'], ['pH', 'urine'], [], ['AM'], ['CO2', 'Calc'], [], ['AM'], ['CO2', 'Calc', 'venous'], [], ['PM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Ionized Calcium'], [], ['PM'], ['Magnesium'], [], ['AM'], ['ALT'], [], ['AM'], ['Alkaline Phosphate'], [], ['AM'], ['AST'], [], ['AM'], ['Amylase'], [], ['AM'], ['Total', 'Bilirubin'], [], ['AM'], ['Triglyceride'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'Replete', 'fiber'], ['strength'], ['rate', 'Advance rate', 'Goal rate'], ['Residual Check', 'feeding', 'residual'], ['Flush', 'water'], ['GI', 'Abdominal', 'Soft', 'Non-tender', 'Bowel sounds'], ['PEG site', 'clean', 'dry'], ['Assessment', 'Nutritional Status'], ['year', 'male', 'PEG placement yesterday', 'tube feed'], ['yesterday', 'tolerated', 'Isosource', 'tube feed ordered', 'changed'], ['Replete', 'fiber', 'morning', 'spoke', 'patient'], ['special tube feed', 'Fibersource', 'HN'], ['formula', 'excess', 'amount', 'protein', 'Noted discharge'], ['progress'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['Tube', 'feeding', 'Fibersource', 'HN', 'goal'], [], ['Check chemistry', 'daily'], ['BS', 'management'], [], [], [], ['Patient asleep'], ['Objective'], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], ['AM'], [], ['medications', 'Multiple', 'Vitamins', 'Furosemide', 'Docusate Sodium'], [], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['Glucose Finger'], [], ['AM'], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'arterial'], [], ['AM'], ['PO2', 'venous'], [], ['PM'], ['PCO2', 'arterial'], [], ['AM'], ['PCO2', 'venous'], [], ['PM'], ['pH', 'arterial'], [], ['AM'], ['pH', 'venous'], [], ['PM'], ['pH', 'urine'], [], ['AM'], ['CO2', 'Calc'], [], ['AM'], ['CO2', 'Calc', 'venous'], [], ['PM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Ionized Calcium'], [], ['AM'], ['Magnesium'], [], ['PM'], ['ALT'], [], ['AM'], ['Alkaline Phosphate'], [], ['AM'], ['AST'], [], ['AM'], ['Amylase'], [], ['AM'], ['Total', 'Bilirubin'], [], ['AM'], ['Triglyceride'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'Non-Standard', 'TPN', 'Date'], [], ['Replete', 'fiber'], ['rate', 'Advance rate', 'Goal rate'], ['Residual Check', 'feeding', 'residual'], ['Flush', 'water'], ['GI', 'Abdominal', 'Soft', 'Non-tender', 'Bowel sounds'], ['PEG site', 'clean', 'dry', 'gravity drainage'], ['Assessment', 'Nutritional Status'], ['year', 'male', 'Mitral valve endocarditis', 'preop stroke', 'MVR'], ['debridement', 'aortic valve [**', 'patient', 'evaluation'], ['TPN', 'weekend', 'PEG', 'PEG'], ['yesterday', 'plan', 'tube feeds', 'current', 'tube feed'], ['meeting', 'patient'], ['Noted', 'patient', 'post'], ['fluid restricted formula'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['TPN'], ['tube feed'], ['Tube feeding', 'Isosource 1.5cal goal'], [], ['Start tube', 'adv', 'tol'], ['Check chemistry', 'daily'], ['BS', 'management'], [], [], [], ['patient'], ['Objective'], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], ['AM'], [], ['medications', 'D5 @10 ml/hr', 'KCl', 'repletion', 'RISS', 'IV'], ['lansoprazole', 'famotidine'], ['Labs'], ['Value'], [], ['Glucose'], [], ['PM'], ['Glucose Finger'], [], [], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'arterial'], [], ['AM'], ['PO2', 'venous'], [], ['PM'], ['PCO2', 'arterial'], [], ['AM'], ['PCO2', 'venous'], [], ['PM'], ['pH', 'arterial'], [], ['AM'], ['pH', 'venous'], [], ['PM'], ['pH', 'urine'], [], ['AM'], ['CO2', 'Calc'], [], ['AM'], ['CO2', 'Calc', 'venous'], [], ['PM'], ['Albumin'], [], ['PM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Ionized Calcium'], [], ['AM'], ['Magnesium'], [], ['AM'], ['ALT'], [], ['AM'], ['Alkaline Phosphate'], [], ['AM'], ['AST'], [], ['AM'], ['Amylase'], [], ['AM'], ['Total', 'Bilirubin'], [], ['AM'], ['Triglyceride'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'NPO'], ['GI', 'soft', 'hypoactive bowel sounds'], ['Assessment', 'Nutritional Status'], ['Specifics', 'Patient s/p video swallow', 'patient'], ['NPO', 'consult', 'PPN', 'recommendations', 'PA'], ['plan', 'PEG placement', 'Monday', 'supplement', 'nutrition'], ['parenteral nutrition', 'PEG', 'Patient', 'PICC'], ['Day', 'TPN', 'ordered', 'NGT', 'week'], ['team', 'patient'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['Day', 'TPN'], ['glycemic control', 'goal', 'TPN'], ['amino'], ['Check', 'TG', 'lipids'], ['PEG', 'Isosource', 'HN'], ['goal', 'protein'], ['questions'], [], [], ['Patient asleep', 'Name8', 'MD', 'RN', 'patient', 'po food', 'supplements'], ['Objective'], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], ['AM'], ['fluid'], [], ['Ideal body weight'], ['Ideal body weight'], ['Adjusted'], ['Usual body weight'], ['Usual body weight'], [], [], [], [], ['Diagnosis', 'MITRAL VALVE'], ['PMHx', 'no', 'years'], ['Food allergies', 'intolerances'], ['medications', 'Furosemide', 'Milrinone', 'Multivitamins', 'Thiamine'], ['FoLIC Acid', 'Nicotine', 'Patch', 'Heparin', 'Docusate Sodium', 'Nafcillin'], ['Potassium Chloride'], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'venous'], [], ['PM'], ['PCO2', 'venous'], [], ['PM'], ['pH', 'venous'], [], ['PM'], ['pH', 'urine'], [], ['PM'], ['CO2', 'Calc', 'venous'], [], ['PM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Magnesium'], [], ['AM'], ['ALT'], [], ['AM'], ['Alkaline Phosphate'], [], ['AM'], ['AST'], [], ['AM'], ['Total', 'Bilirubin'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'Regular', 'Supplement', 'Ensure'], ['Plus breakfast', 'lunch', 'dinner\n'], ['GI', 'Abdominal', 'Soft', 'Non-tender', 'Bowel sounds'], ['Extremities', 'Right lower extremity edema', 'Absent', 'Left lower extremity'], ['edema'], ['Skin', 'Rash', 'upper', 'occ petechiae'], ['Assessment', 'Nutritional Status'], ['risk', 'malnutrition'], ['Patient', 'risk', 'Low', 'intake', 'illness', 'multipl'], ['non-hemorrhagic'], ['infarcts', 'suspicious', 'septic emboli'], ['Estimated Nutritional Needs'], ['Calories', 'BEE'], ['Protein'], ['Fluid'], ['Calculations', 'Admit weight'], ['Estimation', 'intake', 'Inadequate'], ['Estimation', 'current', 'intake', 'Inadequate'], ['Specifics'], ['year', 'male', 'staphylococcus aureus', 'bacterial'], ['endocarditis', 'severe', 'mitral regurgitation [**3'], ['vegetations', 'flail leaflet', 'Patient transferred', 'CT surgery', 'evaluation', 'management'], ['Patient', 'swallow', 'evaluation', 'regular diet'], ['patient', 'spoke', 'morning'], ['NGT', 'placement'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['Po', 'tolerance'], ['Tube', 'feeding', 'recommendations', 'Nutren Pulmonary goal'], [], ['Monitor tube feed tolerance'], ['Check chemistry', 'daily', 'replete'], ['phos binder', 'serum phos', 'elevated'], ['Start regular', 'serum glucose'], [], [], [], [], ['Patient asleep', 'Name8', 'MD', 'RN', 'patient', 'po food', 'supplements'], ['Objective'], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], ['AM'], ['fluid'], [], ['Ideal body weight'], ['Ideal body weight'], ['Adjusted'], ['Usual body weight'], ['Usual body weight'], [], [], [], [], ['Diagnosis', 'MITRAL VALVE'], ['PMHx', 'no', 'years'], ['Food allergies', 'intolerances'], ['medications', 'Furosemide', 'Milrinone', 'Multivitamins', 'Thiamine'], ['FoLIC Acid', 'Nicotine', 'Patch', 'Heparin', 'Docusate Sodium', 'Nafcillin'], ['Potassium Chloride'], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'venous'], [], ['PM'], ['PCO2', 'venous'], [], ['PM'], ['pH', 'venous'], [], ['PM'], ['pH', 'urine'], [], ['PM'], ['CO2', 'Calc', 'venous'], [], ['PM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Magnesium'], [], ['AM'], ['ALT'], [], ['AM'], ['Alkaline Phosphate'], [], ['AM'], ['AST'], [], ['AM'], ['Total', 'Bilirubin'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'Regular', 'Supplement', 'Ensure'], ['Plus breakfast', 'lunch', 'dinner\n'], ['GI', 'Abdominal', 'Soft', 'Non-tender', 'Bowel sounds'], ['Extremities', 'Right lower extremity edema', 'Absent', 'Left lower extremity'], ['edema'], ['Skin', 'Rash', 'upper', 'occ petechiae'], ['Assessment', 'Nutritional Status'], ['risk', 'malnutrition'], ['Patient', 'risk', 'Low', 'intake', 'illness', 'multipl'], ['non-hemorrhagic'], ['infarcts', 'suspicious', 'septic emboli'], ['Estimated Nutritional Needs'], ['Calories', 'BEE'], ['Protein'], ['Fluid'], ['Calculations', 'Admit weight'], ['Estimation', 'intake', 'Inadequate'], ['Estimation', 'current', 'intake', 'Inadequate'], ['Specifics'], ['year', 'male', 'staphylococcus aureus', 'bacterial'], ['endocarditis', 'severe', 'mitral regurgitation [**3'], ['vegetations', 'flail leaflet', 'Patient transferred', 'CT surgery', 'evaluation', 'management'], ['Patient', 'swallow', 'evaluation', 'regular diet'], ['patient', 'spoke', 'morning'], ['NGT', 'placement'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['Po', 'tolerance'], ['Tube', 'feeding', 'recommendations', 'Nutren Pulmonary goal'], [], ['Monitor tube feed tolerance'], ['Check chemistry', 'daily', 'replete'], ['phos binder', 'serum phos', 'elevated'], ['Start regular', 'serum glucose'], [], [], [], ['Cardiology Teaching', 'Physician', 'Note'], ['day', 'examined', 'physically present'], ['resident', 'fellow', 'portions', 'services'], ['plans'], ['remarks'], ['Medical Decision Making'], ['Patient', 'improving', 'aggressive', 'diuresis'], ['initiation', 'Milrinone', 'dyspneic', 'saturations'], ['Renal service', 'ARF', 'multifactorial', 'sediment'], ['ATM', 'Createnine', 'stable', 'speaking'], ['somnolent', 'wife', 'night'], ['WBC', 'K', 'K', 'continuing', 'Nafcillin'], ['bllod cultures', 'fever', 'spikes', 'fevers'], ['image', 'abdomen', 'intermittent'], ['abdominal pain', 'C-[**Doctor First Name 91**'], ['delay surgery'], ['Entered', 'By:[**Name (NI) **] [**Last Name (NamePattern1) **]', 'MD'], ['on:[**2113-1-20**]', 'PM'], [], ['patient'], ['Objective'], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], ['AM'], [], ['medications', 'Milrinone', 'protonix'], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'arterial'], [], ['AM'], ['PO2', 'venous'], [], ['PM'], ['PCO2', 'arterial'], [], ['AM'], ['PCO2', 'venous'], [], ['PM'], ['pH', 'arterial'], [], ['AM'], ['pH', 'venous'], [], ['PM'], ['pH', 'urine'], [], ['PM'], ['CO2', 'Calc'], [], ['AM'], ['CO2', 'Calc', 'venous'], [], ['PM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Magnesium'], [], ['AM'], ['ALT'], [], ['AM'], ['Alkaline Phosphate'], [], ['AM'], ['AST'], [], ['AM'], ['Total', 'Bilirubin'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'Diet', 'Regular/ heart healthy'], ['TID'], ['GI', 'abd soft', 'bowel sounds'], ['Assessment', 'Nutritional Status'], ['year', 'male', 'staphylococcus aureus', 'bacterial'], ['endocarditis', 'severe', 'mitral regurgitation [**3'], ['vegetations', 'flail leaflet', 'Patient transferred', 'CT surgery', 'evaluation', 'management'], ['Patient', 'swallow', 'evaluation', 'regular diet'], ['patient'], ['mental status'], ['Team', 'NGT', 'tube feeds'], ['feeding', 'recommendations'], ['amount'], ['patient'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['estimated', 'recommend', 'Nutren Pulmonary\n'], [], ['po', 'intake', 'mental status', 'tube\n'], ['feeds'], ['g-'], [], [], ['intub'], ['Objective'], ['medications', 'Multivitamins', 'FoLIC Acid', 'Pantoprazole'], ['Potassium Chloride', 'Norepinephrine drip'], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'arterial'], [], ['AM'], ['PO2', 'venous'], [], ['PM'], ['PCO2', 'arterial'], [], ['AM'], ['PCO2', 'venous'], [], ['PM'], ['pH', 'arterial'], [], ['AM'], ['pH', 'venous'], [], ['PM'], ['pH', 'urine'], [], ['PM'], ['CO2', 'Calc'], [], ['AM'], ['CO2', 'Calc', 'venous'], [], ['PM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Magnesium'], [], ['AM'], ['ALT'], [], ['AM'], ['Alkaline Phosphate'], [], ['AM'], ['AST'], [], ['AM'], ['Amylase'], [], ['AM'], ['Total', 'Bilirubin'], [], ['AM'], ['Triglyceride'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'Nutren Pulmonary Full strength'], ['Banana flakes'], ['rate', 'Advance rate', 'Goal rate'], ['Residual Check', 'feeding', 'residual'], ['water', 'q8h', 'morning'], ['NPO', 'Procedure Start', '12:01AM Procedure', 'CSURG'], [], ['resume diet', 'procedure'], ['GI', 'soft', 'ND', 'NT', 'NBS'], ['Ext', 'pulses', 'edema', 'extremtiies'], ['Assessment', 'Nutritional Status'], ['year', 'male', 'staphlyococcus aureus', 'bacterial'], ['endocarditis', 'severe', 'mitral regurgitation [**3'], ['vegetations', 'flail leaflet', 'patient', 'AVR'], ['MVR', 'debridement', 'epidural abscess', 'Patient'], ['nutrition', 'admission', 'tube feed'], ['high risk', 'malnutrition', 'post cardiac'], ['surgery', 'restart tube feed', 'patient'], ['food', 'admission'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['Multivitamin', 'Mineral supplement', 'discontinue'], ['tube feed restarts'], ['Tube', 'feeding', 'recommendations', 'restart tube feed'], ['Check chemistry', 'daily', 'replete'], ['Start regular', 'serum glucose'], [], [], [], [], ['Wt'], ['IBW'], ['BMI'], ['Diabetes', 'Dyslipidemia', 'Hypertension'], ['worst', 'left posterior cerebral artery', 'infarct(neurologic\n'], ['deficits', 'left sided facial droop', 'right sided neglect', 'right\n'], ['sided hemiparesis', 'expressive aphasia'], ['MVR(29mm St. [**', 'Mechanical Valve', 'Debridement', 'Aortic Valve'], ['Teeth extraction'], ['Diet Order'], ['year', 'male', 'rehab', 'M. ', 'Patient'], ['hospital CT', 'depressed', 'right frontal sinus', 'Patient'], ['transferred'], ['Potential', 'nutrition risk', 'Patient', 'monitored'], ['intervention'], ['Comments'], [], [], ['Wt'], ['IBW'], ['BMI'], ['Diabetes', 'Dyslipidemia', 'Hypertension'], ['worst', 'left posterior cerebral artery', 'infarct(neurologic\n'], ['deficits', 'left sided facial droop', 'right sided neglect', 'right\n'], ['sided hemiparesis', 'expressive aphasia'], ['MVR(29mm St. [**', 'Mechanical Valve', 'Debridement', 'Aortic Valve'], ['Teeth extraction'], ['Diet Order'], ['year', 'male', 'coumadin', 'prosthetic mitral valve'], ['Staphylococcal endocarditis', 'MV', 'AV', 'c/b multiple', 'embolic'], ['strokes', 'rehab s/p fall', 'Patient', 'diet'], ['vomiting', 'Patient reports', 'po', 'intake'], ['Patient', 'wt loss', 'PTA', 'usual body'], ['supplements', 'increase', 'caloric intake'], ['Recommendations'], ['Encourage pos', 'supplements'], ['TID'], ['questions'], [], [], ['oriented'], ['Objective'], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], ['AM'], [], ['medications', 'Ranitidine', 'ABX', 'Folic Acid', 'Thiamine'], ['Multi-vitamin', 'lasix', 'Colace (Held)', 'KCl', 'repletion'], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['Glucose Finger'], [], [], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'arterial'], [], ['AM'], ['PO2', 'venous'], [], ['PM'], ['PCO2', 'arterial'], [], ['AM'], ['PCO2', 'venous'], [], ['PM'], ['pH', 'arterial'], [], ['AM'], ['pH', 'venous'], [], ['PM'], ['pH', 'urine'], [], ['AM'], ['CO2', 'Calc'], [], ['AM'], ['CO2', 'Calc', 'venous'], [], ['PM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Ionized Calcium'], [], ['AM'], ['Magnesium'], [], ['AM'], ['ALT'], [], ['AM'], ['Alkaline Phosphate'], [], ['AM'], ['AST'], [], ['AM'], ['Amylase'], [], ['AM'], ['Total', 'Bilirubin'], [], ['AM'], ['Triglyceride'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'Diet', 'Ground solids'], ['liquids', 'Ensure Pudding', 'Carnation Instant', 'Breakfast', 'meals'], ['calorie counts'], ['GI', 'soft', 'bowel sounds', 'green liquid stool'], ['Assessment', 'Nutritional Status'], ['Estimation', 'current', 'intake', 'Inadequate'], ['Specifics'], ['Patient', 'MVR', 'AVR', 'SLP'], ['recommended', 'consistency diet', 'supervision', 'Name8'], ['RN', 'patient', 'Ensure pudding', 'Carnation Instant'], ['shake', 'AM', 'encouragement', 'Patient'], ['bites', 'picky eater', 'RN', 'reports wife'], ['foods', 'patient', 'Calorie counts', 'Concerned'], ['nutrition status', 'poor'], [], [], ['tube feed', 'recent surgery'], ['supplemental tube', 'nutrition\n'], ['post-op', 'recovery'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['diet', 'nutrition support'], ['Encourage/assist with'], ['Encourage wife', 'food preference list', 'food\n'], ['Calorie counts'], ['record', 'kitchen', 'receipt'], ['eaten'], ['Oral supplements'], ['Multivitamin', 'Mineral supplement'], ['Tube', 'feeding', 'recommendations'], ['NGT', 'beginning tube', 'feeds'], ['poor'], ['feed goal', 'Nutren Pulmonary @ 45ml/hr'], ['calories', 'protein'], ['Check chemistry', 'daily'], ['page'], [], [], ['extubated'], ['Objective'], ['Height'], ['Admit weight'], ['Daily weight'], ['Weight change'], ['BMI'], [], [], ['AM'], [], ['medications', 'Multivitamins'], ['Labs'], ['Value'], [], ['Glucose'], [], ['AM'], ['Glucose Finger'], [], ['PM'], ['BUN'], [], ['AM'], ['Creatinine'], [], ['AM'], ['Sodium'], [], ['AM'], ['Potassium'], [], ['AM'], ['Chloride'], [], ['AM'], ['TCO2'], [], ['AM'], ['PO2', 'arterial'], [], ['AM'], ['PO2', 'venous'], [], ['PM'], ['PCO2', 'arterial'], [], ['AM'], ['PCO2', 'venous'], [], ['PM'], ['pH', 'arterial'], [], ['AM'], ['pH', 'venous'], [], ['PM'], ['pH', 'urine'], [], ['PM'], ['CO2', 'Calc'], [], ['AM'], ['CO2', 'Calc', 'venous'], [], ['PM'], ['Albumin'], [], ['AM'], ['Calcium', 'non-ionized'], [], ['AM'], ['Phosphorus'], [], ['AM'], ['Ionized Calcium'], [], ['AM'], ['Magnesium'], [], ['AM'], ['ALT'], [], ['AM'], ['Alkaline Phosphate'], [], ['AM'], ['AST'], [], ['AM'], ['Amylase'], [], ['AM'], ['Total', 'Bilirubin'], [], ['AM'], ['Triglyceride'], [], ['AM'], ['WBC'], ['K/uL\n'], ['AM'], ['Hgb'], [], ['AM'], ['Hematocrit'], [], ['AM'], ['Current diet', 'nutrition support', 'Nutren Pulmonary Full strength'], ['rate', 'Advance rate', 'Goal rate'], ['Residual Check', 'feeding', 'residual'], ['Flush', 'water q4h'], ['GI', 'soft', 'flesiseal'], ['SKIN', 'stage 2 wounds'], ['Assessment', 'Nutritional Status'], ['year', 'male', 'admitted', '[**1', 'endocarditis', 'MVR', 'aortic'], ['valve debridement', '[**1', 'patient', 'extubated', 'morning', 'Patient'], ['CCU', 'patient', 'minimal', 'nutrition'], ['hospital admission', 'po food', 'nutrition\n'], ['supplements', 'ccu', 'day', 'tube feed', 'OR'], ['Patient', 'malnutrition'], ['feeding tube', 'restart tube feed', 'temporary', 'nutrition support', 'post'], ['recovery'], ['Medical Nutrition Therapy', 'Plan', 'Recommend'], ['Adv diet'], ['Continue tube feed', 'supplemental nutrition support', 'goal'], ['Nutren Pulmonary goal'], ['Phos binder', 'serum phos', 'elevated'], ['Check chemistry', 'daily'], ['BS', 'management'], [], []]
In [47]:
import gensim
In [48]:
import pandas as pd
pd.options.mode.chained_assignment = None
import numpy as np
import re
from gensim.models import word2vec
from sklearn.manifold import TSNE
import matplotlib.pyplot as plt
%matplotlib inline
In [49]:
model2 = word2vec.Word2Vec(corpus, min_count=1)
In [50]:
model2.wv['arterial']
Out[50]:
array([ 0.00013019, 0.003344 , -0.00708544, -0.00159427, 0.0081028 ,
0.00709473, -0.00361546, 0.00286618, -0.00868333, 0.00618364,
-0.00490692, -0.00322038, 0.00950667, 0.00046824, 0.00780402,
-0.00637494, 0.00521521, 0.00974663, -0.00869079, -0.00548494,
-0.00707419, -0.00477135, -0.00354835, -0.00861325, 0.0077392 ,
-0.00470258, 0.00814598, 0.00517979, -0.00698033, 0.00417376,
0.00571336, -0.00746173, -0.00746034, -0.00247982, -0.00873334,
-0.00131061, -0.00040421, 0.0033197 , 0.00115664, -0.00137005,
-0.00573323, 0.00178918, -0.00099749, 0.00666213, 0.00421187,
0.00455798, 0.00141395, -0.00275581, -0.00444963, -0.00110244,
0.00148484, -0.00316248, -0.00694154, -0.00804633, -0.00956423,
-0.00594124, -0.00204597, -0.00417715, -0.00704359, -0.00347067,
0.00436875, -0.00379218, 0.00851057, 0.00131818, -0.00782046,
0.00945757, 0.00792965, 0.00580111, -0.00718854, 0.00604589,
0.00366075, 0.00538735, 0.00434065, 0.00160183, -0.0030248 ,
0.00848467, 0.0094828 , 0.00410622, -0.00332144, 0.00019091,
0.0014279 , -0.00866013, -0.0085843 , 0.00035536, 0.0009494 ,
-0.00559326, -0.00486383, -0.00689919, 0.00878915, -0.00015642,
-0.00444508, 0.00586895, 0.00914714, -0.00385484, 0.00839188,
0.00535901, 0.00589855, -0.0001103 , 0.0082804 , -0.00724772],
dtype=float32)
In [51]:
import numpy as np
def tsne_plot(model, words):
"Creates a t-SNE model and plots it"
labels = []
tokens = []
for word in words:
if word in model.wv:
tokens.append(model.wv[word])
labels.append(word)
else:
print(f"Skipping '{word}' as it is not present in the model's vocabulary.")
tsne_model = TSNE(perplexity=11, early_exaggeration=12, n_components=2, init='pca', n_iter=1000, random_state=23)
new_values = tsne_model.fit_transform(np.array(tokens)) # Convert tokens to a NumPy array
x = []
y = []
for value in new_values:
x.append(value[0])
y.append(value[1])
plt.figure(figsize=(16, 16))
for i in range(len(x)):
plt.scatter(x[i], y[i])
plt.annotate(labels[i],
xy=(x[i], y[i]),
xytext=(5, 2),
textcoords='offset points',
ha='right',
va='bottom')
plt.show()
In [52]:
vocabs = model2.wv.index_to_key # Access vocabulary using index_to_key
new_v = np.array(list(vocabs))
tsne_plot(model1, new_v)
Skipping 'AM' as it is not present in the model's vocabulary. Skipping 'PM' as it is not present in the model's vocabulary. Skipping 'arterial' as it is not present in the model's vocabulary. Skipping 'venous' as it is not present in the model's vocabulary. Skipping 'pH' as it is not present in the model's vocabulary. Skipping 'patient' as it is not present in the model's vocabulary. Skipping 'PCO2' as it is not present in the model's vocabulary. Skipping 'CO2' as it is not present in the model's vocabulary. Skipping 'nutrition support' as it is not present in the model's vocabulary. Skipping 'intake' as it is not present in the model's vocabulary. Skipping 'Patient' as it is not present in the model's vocabulary. Skipping 'Recommend' as it is not present in the model's vocabulary. Skipping 'Potassium' as it is not present in the model's vocabulary. Skipping 'Chloride' as it is not present in the model's vocabulary. Skipping 'TCO2' as it is not present in the model's vocabulary. Skipping 'Creatinine' as it is not present in the model's vocabulary. Skipping 'Sodium' as it is not present in the model's vocabulary. Skipping 'Glucose' as it is not present in the model's vocabulary. Skipping 'non-ionized' as it is not present in the model's vocabulary. Skipping 'Phosphorus' as it is not present in the model's vocabulary. Skipping 'Magnesium' as it is not present in the model's vocabulary. Skipping 'Current diet' as it is not present in the model's vocabulary. Skipping 'Assessment' as it is not present in the model's vocabulary. Skipping 'Nutritional Status' as it is not present in the model's vocabulary. Skipping 'Medical Nutrition Therapy' as it is not present in the model's vocabulary. Skipping 'Calcium' as it is not present in the model's vocabulary. Skipping 'Plan' as it is not present in the model's vocabulary. Skipping 'Estimation' as it is not present in the model's vocabulary. Skipping 'Labs' as it is not present in the model's vocabulary. Skipping 'Value' as it is not present in the model's vocabulary. Skipping 'feeding' as it is not present in the model's vocabulary. Skipping 'Hgb' as it is not present in the model's vocabulary. Skipping 'K/uL ' as it is not present in the model's vocabulary. Skipping 'urine' as it is not present in the model's vocabulary. Skipping 'Albumin' as it is not present in the model's vocabulary. Skipping 'medications' as it is not present in the model's vocabulary. Skipping 'Admit weight' as it is not present in the model's vocabulary. Skipping 'male' as it is not present in the model's vocabulary. Skipping 'Usual body weight' as it is not present in the model's vocabulary. Skipping 'Ideal body weight' as it is not present in the model's vocabulary. Skipping 'risk' as it is not present in the model's vocabulary. Skipping 'Glucose Finger' as it is not present in the model's vocabulary. Skipping 'Height' as it is not present in the model's vocabulary. Skipping 'Weight change' as it is not present in the model's vocabulary. Skipping 'year' as it is not present in the model's vocabulary. Skipping 'Daily weight' as it is not present in the model's vocabulary. Skipping 'Objective' as it is not present in the model's vocabulary. Skipping 'Total' as it is not present in the model's vocabulary. Skipping 'Specifics' as it is not present in the model's vocabulary. Skipping 'Inadequate' as it is not present in the model's vocabulary. Skipping 'Check chemistry' as it is not present in the model's vocabulary. Skipping 'AST' as it is not present in the model's vocabulary. Skipping 'ALT' as it is not present in the model's vocabulary. Skipping 'Bilirubin' as it is not present in the model's vocabulary. Skipping 'current' as it is not present in the model's vocabulary. Skipping 'Ionized Calcium' as it is not present in the model's vocabulary. Skipping 'Pt' as it is not present in the model's vocabulary. Skipping 'recommendations' as it is not present in the model's vocabulary. Skipping 'goal' as it is not present in the model's vocabulary. Skipping 'malnutrition' as it is not present in the model's vocabulary. Skipping 'management' as it is not present in the model's vocabulary. Skipping 'Replete' as it is not present in the model's vocabulary. Skipping 'evaluation' as it is not present in the model's vocabulary. Skipping 'Food allergies' as it is not present in the model's vocabulary. Skipping 'diet' as it is not present in the model's vocabulary. Skipping 'Protein' as it is not present in the model's vocabulary. Skipping 'Fluid' as it is not present in the model's vocabulary. Skipping 'intolerances' as it is not present in the model's vocabulary. Skipping 'Estimated Nutritional Needs' as it is not present in the model's vocabulary. Skipping 'fiber' as it is not present in the model's vocabulary. Skipping 'Triglyceride' as it is not present in the model's vocabulary. Skipping 'Amylase' as it is not present in the model's vocabulary. Skipping 'tube feed' as it is not present in the model's vocabulary. Skipping 'Adjusted' as it is not present in the model's vocabulary. Skipping 'Diagnosis' as it is not present in the model's vocabulary. Skipping 'Calories' as it is not present in the model's vocabulary. Skipping 'RISS' as it is not present in the model's vocabulary. Skipping 'replete' as it is not present in the model's vocabulary. Skipping 'Goal rate' as it is not present in the model's vocabulary. Skipping 'Residual Check' as it is not present in the model's vocabulary. Skipping 'SLP' as it is not present in the model's vocabulary. Skipping 'residual' as it is not present in the model's vocabulary. Skipping 'Name8' as it is not present in the model's vocabulary. Skipping 'soft' as it is not present in the model's vocabulary. Skipping 'supplements' as it is not present in the model's vocabulary. Skipping 'endocarditis' as it is not present in the model's vocabulary. Skipping 'rate' as it is not present in the model's vocabulary. Skipping 'HN' as it is not present in the model's vocabulary. Skipping 'KCl' as it is not present in the model's vocabulary. Skipping 'Soft' as it is not present in the model's vocabulary. Skipping 'nutrition' as it is not present in the model's vocabulary. Skipping 'Non-tender' as it is not present in the model's vocabulary. Skipping 'protein' as it is not present in the model's vocabulary. Skipping 'morning' as it is not present in the model's vocabulary. Skipping 'mitral regurgitation [**3' as it is not present in the model's vocabulary. Skipping 'bacterial' as it is not present in the model's vocabulary. Skipping 'repletion' as it is not present in the model's vocabulary. Skipping 'Noted' as it is not present in the model's vocabulary. Skipping 'bowel sounds' as it is not present in the model's vocabulary. Skipping 'severe' as it is not present in the model's vocabulary. Skipping 'lytes' as it is not present in the model's vocabulary. Skipping 'flail leaflet' as it is not present in the model's vocabulary. Skipping 'hypocaloric diet' as it is not present in the model's vocabulary. Skipping 'questions' as it is not present in the model's vocabulary. Skipping 'vegetations' as it is not present in the model's vocabulary. Skipping 'Multivitamins' as it is not present in the model's vocabulary. Skipping 'intubated' as it is not present in the model's vocabulary. Skipping 'page' as it is not present in the model's vocabulary. Skipping 'swallow' as it is not present in the model's vocabulary. Skipping 'Bowel sounds' as it is not present in the model's vocabulary. Skipping 'Abdominal' as it is not present in the model's vocabulary. Skipping 'Milrinone' as it is not present in the model's vocabulary. Skipping 'Advance rate' as it is not present in the model's vocabulary. Skipping 'extubate' as it is not present in the model's vocabulary. Skipping 'lasix' as it is not present in the model's vocabulary. Skipping 'Mineral supplement' as it is not present in the model's vocabulary. Skipping 'Multivitamin' as it is not present in the model's vocabulary. Skipping 'plan' as it is not present in the model's vocabulary. Skipping 'tolerance' as it is not present in the model's vocabulary. Skipping 'water' as it is not present in the model's vocabulary. Skipping 'Flush' as it is not present in the model's vocabulary. Skipping 'FoLIC Acid' as it is not present in the model's vocabulary. Skipping 'Patient transferred' as it is not present in the model's vocabulary. Skipping 'regular diet' as it is not present in the model's vocabulary. Skipping 'Nutren Pulmonary goal' as it is not present in the model's vocabulary. Skipping 'BS' as it is not present in the model's vocabulary. Skipping 'serum phos' as it is not present in the model's vocabulary. Skipping 'elevated' as it is not present in the model's vocabulary. Skipping 'Isosource' as it is not present in the model's vocabulary. Skipping 'Start regular' as it is not present in the model's vocabulary. Skipping 'serum glucose' as it is not present in the model's vocabulary. Skipping 'spoke' as it is not present in the model's vocabulary. Skipping 'poor' as it is not present in the model's vocabulary. Skipping 'Patient asleep' as it is not present in the model's vocabulary. Skipping 'calories' as it is not present in the model's vocabulary. Skipping 'Potassium Chloride' as it is not present in the model's vocabulary. Skipping 'edema' as it is not present in the model's vocabulary. Skipping 'staphylococcus aureus' as it is not present in the model's vocabulary. Skipping 'increase' as it is not present in the model's vocabulary. Skipping 'po food' as it is not present in the model's vocabulary. Skipping 'Calorie counts' as it is not present in the model's vocabulary. Skipping 'tolerated' as it is not present in the model's vocabulary. Skipping 'famotidine' as it is not present in the model's vocabulary. Skipping 'tube feedings' as it is not present in the model's vocabulary. Skipping 'debridement' as it is not present in the model's vocabulary. Skipping 'tol' as it is not present in the model's vocabulary. Skipping 'Docusate Sodium' as it is not present in the model's vocabulary. Skipping 'Furosemide' as it is not present in the model's vocabulary. Skipping 'CT surgery' as it is not present in the model's vocabulary. Skipping 'Adequate' as it is not present in the model's vocabulary. Skipping 'restart tube feed' as it is not present in the model's vocabulary. Skipping 'consult' as it is not present in the model's vocabulary. Skipping 'extubated' as it is not present in the model's vocabulary. Skipping 'right sided neglect' as it is not present in the model's vocabulary. Skipping 'infarct(neurologic ' as it is not present in the model's vocabulary. Skipping 'Bg' as it is not present in the model's vocabulary. Skipping 'amount' as it is not present in the model's vocabulary. Skipping 'nutritional' as it is not present in the model's vocabulary. Skipping 'left sided facial droop' as it is not present in the model's vocabulary. Skipping 'right ' as it is not present in the model's vocabulary. Skipping 'Cont' as it is not present in the model's vocabulary. Skipping 'sided hemiparesis' as it is not present in the model's vocabulary. Skipping 'dry' as it is not present in the model's vocabulary. Skipping 'clean' as it is not present in the model's vocabulary. Skipping 'PEG site' as it is not present in the model's vocabulary. Skipping 'expressive aphasia' as it is not present in the model's vocabulary. Skipping 'MVR(29mm St. [**' as it is not present in the model's vocabulary. Skipping 'left posterior cerebral artery' as it is not present in the model's vocabulary. Skipping 'Change' as it is not present in the model's vocabulary. Skipping 'worst' as it is not present in the model's vocabulary. Skipping 'issue' as it is not present in the model's vocabulary. Skipping 'right parietal-occipital ' as it is not present in the model's vocabulary. Skipping 'SAH' as it is not present in the model's vocabulary. Skipping 'left intraparenchymal bleed' as it is not present in the model's vocabulary. Skipping 'contre-coup injury' as it is not present in the model's vocabulary. Skipping 'post' as it is not present in the model's vocabulary. Skipping 'goal TF' as it is not present in the model's vocabulary. Skipping 'tube feeds' as it is not present in the model's vocabulary. Skipping 'per chart' as it is not present in the model's vocabulary. Skipping 'Debridement' as it is not present in the model's vocabulary. Skipping 'gag' as it is not present in the model's vocabulary. Skipping 'Wt' as it is not present in the model's vocabulary. Skipping 'needs' as it is not present in the model's vocabulary. Skipping 'IBW' as it is not present in the model's vocabulary. Skipping 'Diabetes' as it is not present in the model's vocabulary. Skipping 'Dyslipidemia' as it is not present in the model's vocabulary. Skipping 'Hypertension' as it is not present in the model's vocabulary. Skipping 'Mechanical Valve' as it is not present in the model's vocabulary. Skipping 'Diet Order' as it is not present in the model's vocabulary. Skipping 'Aortic Valve' as it is not present in the model's vocabulary. Skipping 'oriented' as it is not present in the model's vocabulary. Skipping 'advanced' as it is not present in the model's vocabulary. Skipping 'time' as it is not present in the model's vocabulary. Skipping 'nutritional decline' as it is not present in the model's vocabulary. Skipping 'Potential' as it is not present in the model's vocabulary. Skipping 'nutrition risk' as it is not present in the model's vocabulary. Skipping '[**1' as it is not present in the model's vocabulary. Skipping 'comfort' as it is not present in the model's vocabulary. Skipping 'monitored' as it is not present in the model's vocabulary. Skipping 'intervention' as it is not present in the model's vocabulary. Skipping 'Comments' as it is not present in the model's vocabulary. Skipping 'multiple' as it is not present in the model's vocabulary. Skipping 'admitted' as it is not present in the model's vocabulary. Skipping 'progress' as it is not present in the model's vocabulary. Skipping 'aspiration' as it is not present in the model's vocabulary. Skipping 'protonix' as it is not present in the model's vocabulary. Skipping 'initiation' as it is not present in the model's vocabulary. Skipping 'Teeth extraction' as it is not present in the model's vocabulary. Skipping 'Multi-vitamin' as it is not present in the model's vocabulary. Skipping 's/p' as it is not present in the model's vocabulary. Skipping 'feeding tube' as it is not present in the model's vocabulary. Skipping 'team' as it is not present in the model's vocabulary. Skipping 'Fiber' as it is not present in the model's vocabulary. Skipping 'PEG placement' as it is not present in the model's vocabulary. Skipping 'soft/+bs' as it is not present in the model's vocabulary. Skipping 'infusing' as it is not present in the model's vocabulary. Skipping 'NamePattern1' as it is not present in the model's vocabulary. Skipping 'preop stroke' as it is not present in the model's vocabulary. Skipping 'Carnation Instant' as it is not present in the model's vocabulary. Skipping 'nutrition ' as it is not present in the model's vocabulary. Skipping 'recovery' as it is not present in the model's vocabulary. Skipping 'head trauma' as it is not present in the model's vocabulary. Skipping 'deficits' as it is not present in the model's vocabulary. Skipping 'Left lower extremity' as it is not present in the model's vocabulary. Skipping 'day' as it is not present in the model's vocabulary. Skipping 'infarcts' as it is not present in the model's vocabulary. Skipping 'non-hemorrhagic' as it is not present in the model's vocabulary. Skipping 'multipl' as it is not present in the model's vocabulary. Skipping 'Head Bleed' as it is not present in the model's vocabulary. Skipping 'illness' as it is not present in the model's vocabulary. Skipping 'Low' as it is not present in the model's vocabulary. Skipping 'occ petechiae' as it is not present in the model's vocabulary. Skipping 'upper' as it is not present in the model's vocabulary. Skipping 'Extremities' as it is not present in the model's vocabulary. Skipping 'Rash' as it is not present in the model's vocabulary. Skipping 'Skin' as it is not present in the model's vocabulary. Skipping 'fentanyl' as it is not present in the model's vocabulary. Skipping 'Pls page' as it is not present in the model's vocabulary. Skipping 'Pro' as it is not present in the model's vocabulary. Skipping 'Absent' as it is not present in the model's vocabulary. Skipping 'suspicious' as it is not present in the model's vocabulary. Skipping 'DM' as it is not present in the model's vocabulary. Skipping 'septic emboli' as it is not present in the model's vocabulary. Skipping 'Calculations' as it is not present in the model's vocabulary. Skipping 'Po' as it is not present in the model's vocabulary. Skipping 'K' as it is not present in the model's vocabulary. Skipping 'OGT' as it is not present in the model's vocabulary. Skipping 'mental status' as it is not present in the model's vocabulary. Skipping 'Monitor tube feed tolerance' as it is not present in the model's vocabulary. Skipping 'phos binder' as it is not present in the model's vocabulary. Skipping 'Stage IV splenic laceration' as it is not present in the model's vocabulary. Skipping 'minimal residuals' as it is not present in the model's vocabulary. Skipping 'kcals/89 g Pro' as it is not present in the model's vocabulary. Skipping 'changing TF' as it is not present in the model's vocabulary. Skipping 'Pertinent medications' as it is not present in the model's vocabulary. Skipping 'LR' as it is not present in the model's vocabulary. Skipping 'Right lower extremity edema' as it is not present in the model's vocabulary. Skipping 'placement' as it is not present in the model's vocabulary. Skipping 'dinner ' as it is not present in the model's vocabulary. Skipping 'S/P Fall' as it is not present in the model's vocabulary. Skipping 'ssri' as it is not present in the model's vocabulary. Skipping 'feeds' as it is not present in the model's vocabulary. Skipping 'cirrhosis' as it is not present in the model's vocabulary. Skipping 'smoker' as it is not present in the model's vocabulary. Skipping 'colace' as it is not present in the model's vocabulary. Skipping 'lunch' as it is not present in the model's vocabulary. Skipping 'years' as it is not present in the model's vocabulary. Skipping 'no' as it is not present in the model's vocabulary. Skipping 'PMHx' as it is not present in the model's vocabulary. Skipping 'MITRAL VALVE' as it is not present in the model's vocabulary. Skipping 'fluid' as it is not present in the model's vocabulary. Skipping 'Nutren Pulmonary Full strength' as it is not present in the model's vocabulary. Skipping 'etoh' as it is not present in the model's vocabulary. Skipping 'advance diet' as it is not present in the model's vocabulary. Skipping 'Plus breakfast' as it is not present in the model's vocabulary. Skipping 'admission' as it is not present in the model's vocabulary. Skipping 'Ensure' as it is not present in the model's vocabulary. Skipping 'Nicotine' as it is not present in the model's vocabulary. Skipping 'Patch' as it is not present in the model's vocabulary. Skipping 'Day' as it is not present in the model's vocabulary. Skipping 'po' as it is not present in the model's vocabulary. Skipping 'Regular' as it is not present in the model's vocabulary. Skipping 'Supplement' as it is not present in the model's vocabulary. Skipping 'salivary glands' as it is not present in the model's vocabulary. Skipping 'Will sign' as it is not present in the model's vocabulary. Skipping 'damaged' as it is not present in the model's vocabulary. Skipping 'swallowing' as it is not present in the model's vocabulary. Skipping 'focused care' as it is not present in the model's vocabulary. Skipping 'increased' as it is not present in the model's vocabulary. Skipping 'Pt s/p LRRT [**4' as it is not present in the model's vocabulary. Skipping 'c/b hypoxia' as it is not present in the model's vocabulary. Skipping 'requirements' as it is not present in the model's vocabulary. Skipping 'clears' as it is not present in the model's vocabulary. Skipping 'difficulty' as it is not present in the model's vocabulary. Skipping 'measures' as it is not present in the model's vocabulary. Skipping 'Clinically improving' as it is not present in the model's vocabulary. Skipping 'floor' as it is not present in the model's vocabulary. Skipping 'transition' as it is not present in the model's vocabulary. Skipping 'medication' as it is not present in the model's vocabulary. Skipping 'Screening' as it is not present in the model's vocabulary. Skipping 's/s' as it is not present in the model's vocabulary. Skipping 'goal rate' as it is not present in the model's vocabulary. Skipping 'facial fx ' as it is not present in the model's vocabulary. Skipping 'LF' as it is not present in the model's vocabulary. Skipping 'docusate' as it is not present in the model's vocabulary. Skipping 'Anticipate diet advancement' as it is not present in the model's vocabulary. Skipping 'Advance diet' as it is not present in the model's vocabulary. Skipping 'pepcid' as it is not present in the model's vocabulary. Skipping 'Please page' as it is not present in the model's vocabulary. Skipping 'prn' as it is not present in the model's vocabulary. Skipping 'Name3' as it is not present in the model's vocabulary. Skipping 'cough' as it is not present in the model's vocabulary. Skipping 'patient's' as it is not present in the model's vocabulary. Skipping 'adequate' as it is not present in the model's vocabulary. Skipping 'Non-distended' as it is not present in the model's vocabulary. Skipping 'HTN' as it is not present in the model's vocabulary. Skipping 'Pplease page' as it is not present in the model's vocabulary. Skipping 'eval' as it is not present in the model's vocabulary. Skipping 'resume TF's' as it is not present in the model's vocabulary. Skipping 'Pt s/p' as it is not present in the model's vocabulary. Skipping 'estimated kcal' as it is not present in the model's vocabulary. Skipping 'days' as it is not present in the model's vocabulary. Skipping 'kcals/112 gr aa' as it is not present in the model's vocabulary. Skipping 'thiamin' as it is not present in the model's vocabulary. Skipping 'Increase' as it is not present in the model's vocabulary. Skipping 'folate' as it is not present in the model's vocabulary. Skipping 'vua TF' as it is not present in the model's vocabulary. Skipping 'bowel' as it is not present in the model's vocabulary. Skipping 'regimen' as it is not present in the model's vocabulary. Skipping 'MOM' as it is not present in the model's vocabulary. Skipping 'reglan' as it is not present in the model's vocabulary. Skipping 'underfeeding' as it is not present in the model's vocabulary. Skipping 'HN@60mL/hr' as it is not present in the model's vocabulary. Skipping '[**2027**]-2200' as it is not present in the model's vocabulary. Skipping 'Phos binder' as it is not present in the model's vocabulary. Skipping 'breast ca' as it is not present in the model's vocabulary. Skipping 'discontinue' as it is not present in the model's vocabulary. Skipping 'NT' as it is not present in the model's vocabulary. Skipping 'Ext' as it is not present in the model's vocabulary. Skipping 'pulses' as it is not present in the model's vocabulary. Skipping 'extremtiies' as it is not present in the model's vocabulary. Skipping 'staphlyococcus aureus' as it is not present in the model's vocabulary. Skipping 'epidural abscess' as it is not present in the model's vocabulary. Skipping 'high risk' as it is not present in the model's vocabulary. Skipping 'post cardiac' as it is not present in the model's vocabulary. Skipping 'surgery' as it is not present in the model's vocabulary. Skipping 'food' as it is not present in the model's vocabulary. Skipping 'tube feed restarts' as it is not present in the model's vocabulary. Skipping 'resume diet' as it is not present in the model's vocabulary. Skipping 'rehab' as it is not present in the model's vocabulary. Skipping 'M. ' as it is not present in the model's vocabulary. Skipping 'hospital CT' as it is not present in the model's vocabulary. Skipping 'depressed' as it is not present in the model's vocabulary. Skipping 'right frontal sinus' as it is not present in the model's vocabulary. Skipping 'transferred' as it is not present in the model's vocabulary. Skipping 'coumadin' as it is not present in the model's vocabulary. Skipping 'prosthetic mitral valve' as it is not present in the model's vocabulary. Skipping 'Staphylococcal endocarditis' as it is not present in the model's vocabulary. Skipping 'c/b multiple' as it is not present in the model's vocabulary. Skipping 'procedure' as it is not present in the model's vocabulary. Skipping 'CSURG' as it is not present in the model's vocabulary. Skipping 'strokes' as it is not present in the model's vocabulary. Skipping 'Regular/ heart healthy' as it is not present in the model's vocabulary. Skipping 'fever' as it is not present in the model's vocabulary. Skipping 'spikes' as it is not present in the model's vocabulary. Skipping 'fevers' as it is not present in the model's vocabulary. Skipping 'image' as it is not present in the model's vocabulary. Skipping 'abdomen' as it is not present in the model's vocabulary. Skipping 'intermittent' as it is not present in the model's vocabulary. Skipping 'abdominal pain' as it is not present in the model's vocabulary. Skipping 'C-[**Doctor First Name 91**' as it is not present in the model's vocabulary. Skipping 'delay surgery' as it is not present in the model's vocabulary. Skipping 'Entered' as it is not present in the model's vocabulary. Skipping 'By:[**Name (NI) **] [**Last Name (NamePattern1) **]' as it is not present in the model's vocabulary. Skipping 'on:[**2113-1-20**]' as it is not present in the model's vocabulary. Skipping 'abd soft' as it is not present in the model's vocabulary. Skipping '12:01AM Procedure' as it is not present in the model's vocabulary. Skipping 'Team' as it is not present in the model's vocabulary. Skipping 'estimated' as it is not present in the model's vocabulary. Skipping 'recommend' as it is not present in the model's vocabulary. Skipping 'Nutren Pulmonary ' as it is not present in the model's vocabulary. Skipping 'tube ' as it is not present in the model's vocabulary. Skipping 'g-' as it is not present in the model's vocabulary. Skipping 'intub' as it is not present in the model's vocabulary. Skipping 'Banana flakes' as it is not present in the model's vocabulary. Skipping 'q8h' as it is not present in the model's vocabulary. Skipping 'Procedure Start' as it is not present in the model's vocabulary. Skipping 'embolic' as it is not present in the model's vocabulary. Skipping 'continuing' as it is not present in the model's vocabulary. Skipping 'water q4h' as it is not present in the model's vocabulary. Skipping 'Encourage/assist with' as it is not present in the model's vocabulary. Skipping 'Encourage wife' as it is not present in the model's vocabulary. Skipping 'food preference list' as it is not present in the model's vocabulary. Skipping 'food ' as it is not present in the model's vocabulary. Skipping 'record' as it is not present in the model's vocabulary. Skipping 'kitchen' as it is not present in the model's vocabulary. Skipping 'receipt' as it is not present in the model's vocabulary. Skipping 'eaten' as it is not present in the model's vocabulary. Skipping 'Oral supplements' as it is not present in the model's vocabulary. Skipping 'beginning tube' as it is not present in the model's vocabulary. Skipping 'feed goal' as it is not present in the model's vocabulary. Skipping 'Nutren Pulmonary @ 45ml/hr' as it is not present in the model's vocabulary. Skipping 'flesiseal' as it is not present in the model's vocabulary. Skipping 'supplemental tube' as it is not present in the model's vocabulary. Skipping 'SKIN' as it is not present in the model's vocabulary. Skipping 'stage 2 wounds' as it is not present in the model's vocabulary. Skipping 'aortic' as it is not present in the model's vocabulary. Skipping 'valve debridement' as it is not present in the model's vocabulary. Skipping 'minimal' as it is not present in the model's vocabulary. Skipping 'hospital admission' as it is not present in the model's vocabulary. Skipping 'ccu' as it is not present in the model's vocabulary. Skipping 'OR' as it is not present in the model's vocabulary. Skipping 'temporary' as it is not present in the model's vocabulary. Skipping 'Adv diet' as it is not present in the model's vocabulary. Skipping 'Continue tube feed' as it is not present in the model's vocabulary. Skipping 'post-op' as it is not present in the model's vocabulary. Skipping 'recent surgery' as it is not present in the model's vocabulary. Skipping 'vomiting' as it is not present in the model's vocabulary. Skipping 'meals' as it is not present in the model's vocabulary. Skipping 'Patient reports' as it is not present in the model's vocabulary. Skipping 'wt loss' as it is not present in the model's vocabulary. Skipping 'usual body' as it is not present in the model's vocabulary. Skipping 'caloric intake' as it is not present in the model's vocabulary. Skipping 'Recommendations' as it is not present in the model's vocabulary. Skipping 'Encourage pos' as it is not present in the model's vocabulary. Skipping 'Colace (Held)' as it is not present in the model's vocabulary. Skipping 'Ground solids' as it is not present in the model's vocabulary. Skipping 'liquids' as it is not present in the model's vocabulary. Skipping 'Ensure Pudding' as it is not present in the model's vocabulary. Skipping 'Breakfast' as it is not present in the model's vocabulary. Skipping 'calorie counts' as it is not present in the model's vocabulary. Skipping 'nutrition status' as it is not present in the model's vocabulary. Skipping 'green liquid stool' as it is not present in the model's vocabulary. Skipping 'recommended' as it is not present in the model's vocabulary. Skipping 'consistency diet' as it is not present in the model's vocabulary. Skipping 'supervision' as it is not present in the model's vocabulary. Skipping 'Ensure pudding' as it is not present in the model's vocabulary. Skipping 'shake' as it is not present in the model's vocabulary. Skipping 'encouragement' as it is not present in the model's vocabulary. Skipping 'bites' as it is not present in the model's vocabulary. Skipping 'picky eater' as it is not present in the model's vocabulary. Skipping 'reports wife' as it is not present in the model's vocabulary. Skipping 'foods' as it is not present in the model's vocabulary. Skipping 'Concerned' as it is not present in the model's vocabulary. Skipping 'bllod cultures' as it is not present in the model's vocabulary. Skipping 'night' as it is not present in the model's vocabulary. Skipping 'tongue ca' as it is not present in the model's vocabulary. Skipping 'supplemental nutrition support' as it is not present in the model's vocabulary. Skipping 'Magnesium sulfate' as it is not present in the model's vocabulary. Skipping 'Heparin drip' as it is not present in the model's vocabulary. Skipping 'stool' as it is not present in the model's vocabulary. Skipping 'mitral valve endocarditis' as it is not present in the model's vocabulary. Skipping 'aortic valve [**1' as it is not present in the model's vocabulary. Skipping 'prolonged' as it is not present in the model's vocabulary. Skipping 'ground solids' as it is not present in the model's vocabulary. Skipping 'thin liquid' as it is not present in the model's vocabulary. Skipping 'video swallow' as it is not present in the model's vocabulary. Skipping 'long term' as it is not present in the model's vocabulary. Skipping 'non-dextrose IV fluids' as it is not present in the model's vocabulary. Skipping 'optimize' as it is not present in the model's vocabulary. Skipping 'post-op healing' as it is not present in the model's vocabulary. Skipping 'lyte' as it is not present in the model's vocabulary. Skipping 'repletions' as it is not present in the model's vocabulary. Skipping 'follow up' as it is not present in the model's vocabulary. Skipping 'Patient oob' as it is not present in the model's vocabulary. Skipping 'tube feed running' as it is not present in the model's vocabulary. Skipping 'strength' as it is not present in the model's vocabulary. Skipping 'PEG placement yesterday' as it is not present in the model's vocabulary. Skipping 'tube feed ordered' as it is not present in the model's vocabulary. Skipping 'changed' as it is not present in the model's vocabulary. Skipping 'Implement' as it is not present in the model's vocabulary. Skipping 'tube feeding' as it is not present in the model's vocabulary. Skipping 'formula' as it is not present in the model's vocabulary. Skipping 'female' as it is not present in the model's vocabulary. Skipping 'ovarian ca' as it is not present in the model's vocabulary. Skipping 'vertigo' as it is not present in the model's vocabulary. Skipping 'falls' as it is not present in the model's vocabulary. Skipping 'normal saline' as it is not present in the model's vocabulary. Skipping 'trauma' as it is not present in the model's vocabulary. Skipping 'body' as it is not present in the model's vocabulary. Skipping 'status' as it is not present in the model's vocabulary. Skipping 'hospital S/P' as it is not present in the model's vocabulary. Skipping 'glucose' as it is not present in the model's vocabulary. Skipping 'home' as it is not present in the model's vocabulary. Skipping 'multiple injuries' as it is not present in the model's vocabulary. Skipping 'Le Forte fx' as it is not present in the model's vocabulary. Skipping 'sinus' as it is not present in the model's vocabulary. Skipping 'orbital fx' as it is not present in the model's vocabulary. Skipping 'facial' as it is not present in the model's vocabulary. Skipping 'tongue swelling' as it is not present in the model's vocabulary. Skipping '[**6-4**' as it is not present in the model's vocabulary. Skipping 'initiating' as it is not present in the model's vocabulary. Skipping 'Check residuals' as it is not present in the model's vocabulary. Skipping 'Monitor lytes' as it is not present in the model's vocabulary. Skipping 'special tube feed' as it is not present in the model's vocabulary. Skipping 'excess' as it is not present in the model's vocabulary. Skipping 'wife' as it is not present in the model's vocabulary. Skipping 'improving' as it is not present in the model's vocabulary. Skipping 'Cardiology Teaching' as it is not present in the model's vocabulary. Skipping 'Physician' as it is not present in the model's vocabulary. Skipping 'Note' as it is not present in the model's vocabulary. Skipping 'examined' as it is not present in the model's vocabulary. Skipping 'physically present' as it is not present in the model's vocabulary. Skipping 'resident' as it is not present in the model's vocabulary. Skipping 'fellow' as it is not present in the model's vocabulary. Skipping 'portions' as it is not present in the model's vocabulary. Skipping 'services' as it is not present in the model's vocabulary. Skipping 'plans' as it is not present in the model's vocabulary. Skipping 'remarks' as it is not present in the model's vocabulary. Skipping 'Medical Decision Making' as it is not present in the model's vocabulary. Skipping 'aggressive' as it is not present in the model's vocabulary. Skipping 'TG' as it is not present in the model's vocabulary. Skipping 'diuresis' as it is not present in the model's vocabulary. Skipping 'dyspneic' as it is not present in the model's vocabulary. Skipping 'saturations' as it is not present in the model's vocabulary. Skipping 'Renal service' as it is not present in the model's vocabulary. Skipping 'multifactorial' as it is not present in the model's vocabulary. Skipping 'sediment' as it is not present in the model's vocabulary. Skipping 'ATM' as it is not present in the model's vocabulary. Skipping 'stable' as it is not present in the model's vocabulary. Skipping 'speaking' as it is not present in the model's vocabulary. Skipping 'somnolent' as it is not present in the model's vocabulary. Skipping 'lipids' as it is not present in the model's vocabulary. Skipping 'Check' as it is not present in the model's vocabulary. Skipping 'Noted discharge' as it is not present in the model's vocabulary. Skipping 'Start tube' as it is not present in the model's vocabulary. Skipping 'Multiple' as it is not present in the model's vocabulary. Skipping 'Vitamins' as it is not present in the model's vocabulary. Skipping 'Non-Standard' as it is not present in the model's vocabulary. Skipping 'Date' as it is not present in the model's vocabulary. Skipping 'gravity drainage' as it is not present in the model's vocabulary. Skipping 'Mitral valve endocarditis' as it is not present in the model's vocabulary. Skipping 'aortic valve [**' as it is not present in the model's vocabulary. Skipping 'weekend' as it is not present in the model's vocabulary. Skipping 'meeting' as it is not present in the model's vocabulary. Skipping 'fluid restricted formula' as it is not present in the model's vocabulary. Skipping 'Tube feeding' as it is not present in the model's vocabulary. Skipping 'Isosource 1.5cal goal' as it is not present in the model's vocabulary. Skipping 'adv' as it is not present in the model's vocabulary. Skipping 'amino' as it is not present in the model's vocabulary. Skipping 'D5 @10 ml/hr' as it is not present in the model's vocabulary. Skipping 'lansoprazole' as it is not present in the model's vocabulary. Skipping 'hypoactive bowel sounds' as it is not present in the model's vocabulary. Skipping 'Patient s/p video swallow' as it is not present in the model's vocabulary. Skipping 'supplement' as it is not present in the model's vocabulary. Skipping 'parenteral nutrition' as it is not present in the model's vocabulary. Skipping 'PICC' as it is not present in the model's vocabulary. Skipping 'ordered' as it is not present in the model's vocabulary. Skipping 'week' as it is not present in the model's vocabulary. Skipping 'glycemic control' as it is not present in the model's vocabulary.
In [53]:
# load pre-trained word2vec embeddings
import gensim
import gensim.downloader as api
info = api.info() # show info about available models/datasets
pretrained_model= api.load("glove-wiki-gigaword-50") # download the model and return as object ready for use
# model = gensim.models.KeyedVectors.load_word2vec_format('PubMed-and-PMC-ri.tar.gz', binary=True)
In [54]:
pretrained_model.most_similar("headache")
Out[54]:
[('headaches', 0.8957463502883911),
('fatigue', 0.8547418117523193),
('pains', 0.8367806673049927),
('aches', 0.8088536262512207),
('nausea', 0.8022516369819641),
('discomfort', 0.789000391960144),
('pain', 0.7766653895378113),
('anxiety', 0.7692658305168152),
('symptom', 0.7564830183982849),
('migraine', 0.7536172866821289)]
In [55]:
new_corpus_in_pretrained_model = []
for word in new_v:
if word in pretrained_model.key_to_index:
new_corpus_in_pretrained_model.append(word)
else:
print(word) # Print out-of-vocabulary words
AM PM pH PCO2 PO2 Calc CO2 nutrition support Patient Recommend NPO Potassium Chloride TCO2 Creatinine BUN Sodium Glucose non-ionized Phosphorus Magnesium Current diet GI Assessment Nutritional Status Medical Nutrition Therapy Calcium Plan Estimation Labs Value WBC Hematocrit Hgb K/uL Albumin Admit weight BMI Usual body weight Ideal body weight Glucose Finger Height Weight change Daily weight Objective Total Specifics Inadequate Check chemistry AST ALT Alkaline Phosphate Bilirubin Ionized Calcium Pt TF Tube Replete NGT Food allergies Protein Fluid Estimated Nutritional Needs Triglyceride Amylase tube feed Adjusted Diagnosis Calories RISS Goal rate Residual Check SLP TPN PEG RN Name8 Fibersource PMH HN KCl Soft MVR Non-tender Diet mitral regurgitation [**3 repletion Noted bowel sounds lytes flail leaflet Thiamine hypocaloric diet Multivitamins Bowel sounds Abdominal Milrinone Advance rate extubate Mineral supplement Multivitamin BEE Flush FoLIC Acid Patient transferred regular diet Nutren Pulmonary goal BS serum phos Isosource Start regular serum glucose Patient asleep Potassium Chloride staphylococcus aureus po food MD Calorie counts famotidine tube feedings Nafcillin Docusate Sodium Furosemide Heparin CT surgery Adequate restart tube feed IV extubated right sided neglect infarct(neurologic Bg left sided facial droop right Cont sided hemiparesis PEG site expressive aphasia MVR(29mm St. [** left posterior cerebral artery Change right parietal-occipital SAH left intraparenchymal bleed contre-coup injury goal TF tube feeds per chart Debridement Wt IBW Diabetes Dyslipidemia Hypertension Mechanical Valve Diet Order Aortic Valve nutritional decline Potential nutrition risk [**1 Comments Ranitidine Teeth extraction Multi-vitamin s/p feeding tube Fiber PEG placement PA soft/+bs NamePattern1 preop stroke Carnation Instant nutrition Folic Acid ABX head trauma Left lower extremity non-hemorrhagic multipl Head Bleed Low occ petechiae Extremities Rash Skin S/P Pls page Pro Absent DM septic emboli Calculations Po OSH K OGT TID mental status CT Monitor tube feed tolerance phos binder Stage IV splenic laceration minimal residuals kcals/89 g Pro changing TF Pertinent medications LR Right lower extremity edema dinner S/P Fall AVR PMHx MITRAL VALVE Nutren Pulmonary Full strength Phenytoin Esmolol Dilantin advance diet Plus breakfast Ensure Nicotine Patch NKFA Day Regular Supplement salivary glands Will sign focused care Pt s/p LRRT [**4 c/b hypoxia O2 PACU Clinically improving Screening MICU CATEGORY goal rate facial fx LF docusate Anticipate diet advancement Advance diet Please page Name3 patient's Non-distended HTN Pplease page resume TF's SLP- Abx Pt s/p IVC estimated kcal BG SS kcals/112 gr aa Increase vua TF MOM reglan underfeeding HN@60mL/hr [**2027**]-2200 XRT Phos binder breast ca ND NT NBS Ext extremtiies staphlyococcus aureus epidural abscess high risk post cardiac tube feed restarts resume diet M. hospital CT right frontal sinus prosthetic mitral valve Staphylococcal endocarditis MV AV c/b multiple CSURG Regular/ heart healthy abdominal pain C-[**Doctor First Name 91** delay surgery Entered By:[**Name (NI) **] [**Last Name (NamePattern1) **] on:[**2113-1-20**] abd soft 12:01AM Procedure Team Nutren Pulmonary tube g- intub Pantoprazole Norepinephrine drip Banana flakes q8h Procedure Start rehab s/p fall water q4h Encourage/assist with Encourage wife food preference list food Oral supplements beginning tube feed goal Nutren Pulmonary @ 45ml/hr flesiseal supplemental tube SKIN stage 2 wounds valve debridement CCU hospital admission OR Adv diet Continue tube feed recent surgery Patient reports wt loss PTA usual body caloric intake Recommendations Encourage pos Colace (Held) Ground solids Ensure Pudding Breakfast calorie counts nutrition status green liquid stool consistency diet Ensure pudding picky eater reports wife Concerned bllod cultures tongue ca supplemental nutrition support Coumadin Lasix Colace Magnesium sulfate Heparin drip mitral valve endocarditis aortic valve [**1 ground solids thin liquid video swallow long term non-dextrose IV fluids post-op healing repletions follow up PRN Patient oob tube feed running PEG placement yesterday tube feed ordered Implement tube feeding ovarian ca polymyalgia NIDDM Dextrose normal saline Obese hospital S/P multiple injuries Le Forte fx orbital fx tongue swelling [**6-4** Check residuals Monitor lytes special tube feed Cardiology Teaching Physician Note physically present Medical Decision Making TG dyspneic saturations Renal service ARF ATM Createnine Check Noted discharge Start tube Multiple Vitamins Non-Standard Date gravity drainage Mitral valve endocarditis aortic valve [** fluid restricted formula Tube feeding Isosource 1.5cal goal D5 @10 ml/hr lansoprazole hypoactive bowel sounds Patient s/p video swallow PPN Monday parenteral nutrition PICC glycemic control SUBJECT_ID
In [56]:
import numpy as np
def tsne_plot(model, words):
"Creates a t-SNE model and plots it"
labels = []
tokens = []
for word in words:
if word in model:
tokens.append(model[word])
labels.append(word)
else:
print(f"Skipping '{word}' as it is not present in the model's vocabulary.")
tsne_model = TSNE(perplexity=11, early_exaggeration=12, n_components=2, init='pca', n_iter=1000, random_state=23)
new_values = tsne_model.fit_transform(np.array(tokens)) # Convert tokens to a NumPy array
x = []
y = []
for value in new_values:
x.append(value[0])
y.append(value[1])
plt.figure(figsize=(16, 16))
for i in range(len(x)):
plt.scatter(x[i], y[i])
plt.annotate(labels[i],
xy=(x[i], y[i]),
xytext=(5, 2),
textcoords='offset points',
ha='right',
va='bottom')
plt.show()
In [57]:
tsne_plot(pretrained_model,new_corpus_in_pretrained_model)
In [ ]:
# import en_core_sci_lg
# nlp = en_core_sci_lg.load()
# doc = []
# for i in range(len(notes)):
# doc.append(nlp(notes[i]))
# displacy.render(doc, style="ent", jupyter=True)
# print("*******************************************************************************************************************************************")
In [ ]:
# import en_ner_craft_md
# nlp = en_ner_craft_md.load()
# doc = []
# for i in range(len(notes)):
# doc.append(nlp(notes[i]))
# displacy.render(doc, style="ent", jupyter=True)
# print("*******************************************************************************************************************************************")
In [ ]:
# import en_ner_jnlpba_md
# nlp = en_ner_jnlpba_md.load()
# doc = []
# for i in range(len(notes)):
# doc.append(nlp(notes[i]))
# displacy.render(doc, style="ent", jupyter=True)
# print("*******************************************************************************************************************************************")
In [ ]:
# import en_ner_bionlp13cg_md
# nlp = en_ner_bionlp13cg_md.load()
# doc = []
# for i in range(len(notes)):
# doc.append(nlp(notes[i]))
# displacy.render(doc, style="ent", jupyter=True)
# print("*******************************************************************************************************************************************")
In [ ]:
# import en_ner_bc5cdr_md
# nlp = en_ner_bc5cdr_md.load()
# doc = []
# for i in range(len(notes)):
# doc.append(nlp(notes[i]))
# displacy.render(doc, style="ent", jupyter=True)
# print("*******************************************************************************************************************************************")
In [ ]: